Highmark Health and Allegheny Health Network have begun a pilot program that seeks to bring a similar reimbursement system to what it uses for health care providers to nonprofits that provide social services.

Recently, health insurers and hospitals have spent a significant amount of time on what are called the social determinants of health, which are factors like housing, food and transportation that impact health and welfare beyond illness and other medical issues. The impact of nonmedical issues on an individual’s health can be vast: Studies show about 80% of health is made up of these social determinants.
Pittsburgh-based Highmark Health is working with 20 nonprofits in Allegheny and Westmoreland counties to pay them for providing services to members and patients who are referred to them for social services, food, job counseling and transportation. It plans to add 20 more nonprofits next year, said Nebeyou Abebe, Highmark Health’s SVP of social determinants of health.

“There’s a recognition across the country that we need to focus on the root causes of poor health, and that is what is driving the work,” said Abebe. Highmark Health has been reaching so-called value-based reimbursement arrangements with doctors, hospitals and, increasingly, pharmaceutical companies in recent years as a way to rein in costs and improve health for patients. The idea is that reimbursement is tied to the patient’s overall health outcome or whether the medication met benchmarks.

The pilot program extends that to social services, which are often referred at the provider or hospital level when there’s a concern. It’s being stepped up even more at AHN and Highmark, where patients and members are being screened for social needs and risk under nine categories that include food insecurity, transportation and social isolation. The patients are then referred first to case managers or social workers at AHN, and then to the social service agencies.

“But historically we have no idea whether that social need has been met,” Abebe said. “The community benefit organizations have now been incentivized to share whether or not they were able to address the need.”

In the case of a referral to a food bank, for instance, then Highmark and AHN will be able to know whether hunger and food insecurity has been addressed. That information can go into the patient’s electronic health record.
“As the result of social need being met, we have removed that barrier to allow the person to focus on their health and well being,” Abebe said. “That’s the kind of insight we need and which is critical to understanding the true impact of addressing the social determinants of health and the long-term health outcomes.” The plan is to use the learnings from the pilot program to scale it up to the other states and regions of Pennsylvania where Highmark Health operates.

“We will also be able to create the much-needed link between those patients whose social needs are addressed and the health care delivery system so that their health outcomes are improved and the burden of the otherwise avoidable health care costs is reduced,” said Dr. Tony Farah, Highmark Health’s EVP and chief medical officer.

The $1 million pilot is being funded by the Richard King Mellon Foundation, which in May 2021 gave Highmark Health a $5 million grant for the development of digital health solutions like its Living Health initiative that provides personalized and digitally-based care for whole health.

“Through the Foundation’s Health & Well-Being program, we seek to ensure that everyone in Allegheny and Westmoreland counties, particularly the most vulnerable, have the opportunity to live a healthy life,” said R.K. Mellon Foundation Director Sam Reiman in a statement.

Abebe said that each nonprofit involved has the opportunity to earn up to $50,000 from the program, depending on the number of referrals. They’ll be paid on a semi-annual basis. “The services CBOs (community benefit organizations) provide are free or low costs. There’s a direct benefit for members to seek out that service to address their social needs, and the CBOs have been doing this for years but they haven’t been properly reimbursed for the services they’re providing,” Abebe said. The pilot will last three years.

Highmark Health members across its service lines will be eligible for the programs, and Abebe said that it’s a myth that it’s just Medicaid and Medicare members who will need the services. He said that within commercial insurance, there are employers who have a large number of employees who are either the working poor or who are struggling with transportation and housing issues. “Maybe the need is greater in the Medicaid space … but we recognize that our commercial customers are also struggling and that we need to provide the right level of support for them as well,” Abebe said. “Many of them aren’t able to address their health needs because of these social barriers.”

The nonprofits involved in the first-year pilot program are: Action-Housing Inc.; Adagio Health Inc.; Allegheny Valley Association of Churches; Cornerstone Care Community Health Centers; Crisis Center North Inc.; Greater Pittsburgh Community Food Bank; Holy Family Institute; Jewish Family and Community Services; Just Harvest; Mon Valley Initiative; Pittsburgh Community Services Inc.; Pittsburgh Financial Empowerment Center; Rebuilding Together; Society of St. Vincent de Paul Central Council of Pittsburgh; South Hills Interfaith Movement; Traveler’s Aid Society of Pittsburgh; Urban League of Greater Pittsburgh Inc.; Wesley Family Services and Westmoreland Community Action.