Scalability of Home-Based, Non-Medical Services is a Non-Trivial Challenge

Popular wisdom claims 80% of our health is impacted by social determinants that can be barriers to the care we’re provided and the outcomes associated with the care we receive. And over the last four to five years, healthcare industry players – providers, health systems, health plans, HHS/CMS, and other parties responsible for the delivery of health care - have finally woken to the importance of addressing social determinants as barriers by providing non-clinical supports and services to their patients and members.

It seems there’s not a vendor serving the healthcare market who’s not in the process of developing, positioning and promoting their product and service offerings as a means of addressing social determinants of health.

Build It and You’ll Have to Deliver It, Deploy It, and Support It

With any vendor’s offering, success depends on someone’s willingness to pay for their offering and their ability to deliver and deploy their specific offering to a large – and growing - user base willing to actually use their product or service. It’s not enough to prove the ‘success’ and value of a product or service via a pilot with a few dozen or even a few hundred individuals unless the outcomes and lessons learned from the pilot confirm that the offering can scale to address the needs of thousands, tens of thousands and greater sized groups.

Accordingly, it’s no surprise that “scalability” has become a hot buzzword among vendors and others touting SDOH-related offerings aimed at addressing barriers to improved health outcomes. Service-related product ideas are notoriously hard to scale.

Definition of Scalability: Scalability is the property of a system to handle a growing amount of work by adding resources to the system.

But just what does scalability mean in the context of delivering, deploying, and supporting SDOH-related services? Especially those considered non-medical in nature?

New Players Bring New Challenges to Scaling Services in the Healthcare Industry

Scaling delivery of products and services that are largely technology-based and deployed with little to no human involvement from a centralized location by a closely managed group of largely professional resources is an entirely different matter than scaling the deployment, configuration, and support of ‘non-technology products’ by non-medical providers across 1000’s of decentralized service locations.

Consider some of the new products and services that Medicare Advantage health plans are approved to provide their members under the recent Special Supplemental Benefits for the Chronically Ill (SSBCI) legislation:

• Food and Produce
• Transportation for Non-Medical Needs
• Indoor Air Quality Equipment and Services
• Assistive Devices and Home Modifications
• Pest Control

All of the above are services are likely to be provided by non-medical providers with various levels of skill, subject to various local regulations in a beneficiary’s home. Scaling the delivery and ongoing support of these types of services and products to large groups of individuals presents new and unique considerations and challenges to healthcare industry players.

Considerations for Scaling Delivery of Non-Medical Products & Services

There are more than a few unique considerations and challenges related to scaling the delivery of non-medical products and services including:

Many SDOH-related Offerings are New Ground for Health Plans, Health Systems, & Providers

With the possible exception of non-emergency medical transportation (NEMT) and care coordination services, most of the non-medical products and services envisioned as reducing or eliminating barriers to health are unchartered territory for the health plans, health systems, and provider practices whose members and patients may enjoy their benefit.

While the general consensus is that plan members and health system patients will benefit from these services, they are largely preventive in nature and their impact on outcomes and their return on investment are not well known. Until a more developed evidence base showcasing the benefits of SDOH-initiatives is available, healthcare organizations will be hesitant to commit significant investment.

Non-Medical Providers Dominate Delivery of SDOH-related Products & Services

The traditional healthcare services model where a patient commutes to a centralized location where services are provided by one or more skilled resources is turned upside down.

For many of the services intended to break down SDOH-related barriers, the provider (medical or non-medical) travels to a patient home (decentralized location) and provides their product and/or service on the recipient’s turf and timeframe.

And issues with delays, availability of needed resources, and unforeseen issues preventing completion of the service event generally impact the service provider more than the patient – which is pretty much the opposite of the traditional healthcare services model.

Established Networks of Vetted Non-Medical Service Providers Do Not Widely Exist

Health plans simply do not currently have meaningful networks of providers to support the non-medical, SDOH-related service needs of their members and existing medical network providers.

While there are a few new startups in this space, UniteUS, Healthify, and Solera Health Network come to mind, they’re mostly unproven and they’re mostly addressing front-end (assessment & referral) and back-end (payment and reporting) functions; the part that technology and contractual relationships go a long way in scaling.

‘Pre-Delivery’ Identification and Selection Assessment Can't Always Be Automated

Given the relative infancy and lack of historical financial experience and quality measures on which to gauge the value of certain SDOH-related offerings, healthcare organizations are looking for objective criteria to help them determine which of their members and patients may benefit the most from SDOH-related products and services. 

Knowing which member or patient to invest in ’upfront’ is not only a smart business decision but in some cases like Medicare, a requirement to document how beneficiaries are selected to receive supplemental benefits.

Some Processes Just Can't be Effectively Automated

While artificial intelligence, predictive analytics, and other ‘black box’ technologies can certainly assist with scalability in this front-end function, many SDOH barriers to health must be physically assessed by a skilled resource. Traditionally, medical professionals may ‘guess’ as to which non-medical benefits their patients may benefit from in their home. In many instances, occupational therapists may need to provide this guidance via in-home visits.

Again, home-based visits to assess need will impact the ability to scale.

Different SDOH-Related Barriers Require Different, Sometimes Scarce Skill Levels

Some SDOH-related services, like non-emergency medical transportation for example, generally require only a licensed driver with auto insurance able to pass a cursory background check. Other services like addressing indoor air quality and installing safety equipment require more specialized, skilled or semi-skilled technical knowledge. On-site home assessments may demand more highly-skilled resources like an occupational therapist.

In all cases, the increasingly tight labor market and a dearth of skilled and semi-skilled labor resources will hamper scalability. Remember the definition of ‘scalability’ noted above?

Products & Services Can Be Subject to Local, County & State Licensing & Regulations

Individuals and companies wanting to provide non-medical products and services able to address barriers to health must meet various levels of licensing and regulations from local city, county, state, and even federal entities. Some of these ‘credentialing needs’ for non-medical providers include:

• Valid driver licensing and auto insurance verification
• Background checks of various levels
• Compliance with local, county, state and federal licensing
• Bonding and insurance
• Certification in various skills, disciplines, and capabilities
• Good standing with the registrar of contracts or local residential licensing boards

Deploying Products & Services in the Field (Home) Can Involve Significant Overhead

For services other than non-medical emergency transportation, traveling to and from a health plan member’s or health system patient’s place of residence can add significant overhead to what might otherwise be a straightforward service provision. And when any myriad of issues arises as they most certainly will, a second trip - or even third or fourth trip - to complete a specific service call can greatly impact the delivery schedule and financial viability to the non-medical provider.

Best Buy’s purchase of GreatCall was an ingenious move that not only opened up Best Buy’s retail channels to Great Calls product but also positioned Best Buy’s Geek Squad to support various levels of virtual and in-person, in-home support of Great Call’s personal emergency response systems.

Non-Medical Offerings Require ‘Post-Service Delivery’ Feedback

On the back end, it’s critical to all those involved in receiving, providing, and paying for these new non-medical services to be able to identify, capture, track and understand how they each benefit. Payers will be loath to pay for services without some understanding of the return on investment obtained.

So, while a lot of front-end beneficiary selection, service scheduling, and back-end reporting may be addressed via scalable automation, a good part of the front-end assessment and post-service referral closure reporting will likely entail a significant manual component – further impacting scalability.

Contracting and Payment for Non-Medical Products & Services

Contracting with non-medical providers and processing payments for the services and products they provide is new ground for healthcare organizations. While it’s expected that a process similar to the traditional method of claim-based billing will be used, there are a lot of moving parts in regard to payment for non-medical services.

And the new cohort of non-medical providers responsible for billing and collecting for their services will need to rapidly climb the often-convoluted healthcare billing curve.

RELATED: Who, What, & How: Understanding New SDOH Payments in Medicare Advantage 

Specific Actions, Thoughts & Ideas to Scale Delivery of Non-Medical Products & Services

In a following post, I’ll share some actions, thoughts, and ideas on how to address what I’ve presented above. In the meantime, consider following me on Twitter and reach out to me here if you’re a health plan, health system, healthcare provider - or even just an individual - with a specific question or need regarding how simple, non-medical products and services can help improve or maintain health outcomes.