Payer-Led Social Needs Interventions Can Reduce Cost of Care for Medicaid Beneficiaries with High Clinical Risk

In recent years, policy makers, payers, and providers have increasingly focused on resolving health-related social needs (HRSNs). The authors evaluated a private payer-led program, Community Connected Care (CCC), which integrates screening and addressing of social needs to enhance members' overall health, and assessed the impact on health care costs among referred Medicaid beneficiaries with high clinical risks. The authors used adjusted difference-in-differences analyses with generalized estimating equation regression models to estimate the average effect of the CCC program intervention on per-member per-month (PMPM) total allowed health care costs among referred high clinical risk Medicaid beneficiaries from January 1, 2022 to December 31, 2022. Differences in average PMPM cost outcomes between an intervention group (referred members who were successfully reached and assessed by program staff) and a control group (referred members who could not be reached) across pre- and postintervention periods (6 months before to 6 months after the index referral date) were compared after baseline covariate adjustment. Additional stratified subgroup analyses were conducted based on additional presence or absence of high social risk. There was a statistically significant decline in PMPM total allowed costs across all high clinical risk Medicaid beneficiaries referred to the CCC model (-US$85 [95% confidence interval (CI), -US$167 to -US$3], P=0.0421). In subgroup analysis, there was a larger and statistically significant decline in total allowed costs (PMPM reduction of -US$181 [95% CI, -US$329 to -US$33], P=0.0163) among the subset of high clinical risk Medicaid beneficiaries with known high social risk at the time of referral. In addition, there were statistically significant reductions in emergency department allowed costs and increases in primary care costs for this high clinical and high social risk Medicaid cohort after referral. By contrast, there was no statistically significant impact on PMPM total allowed costs for Medicaid members who only had high clinical risks without having additional high social risk (-US$40 [95% CI, -US$139 to US$59], P=0.4284). This study suggests that addressing HRSNs among Medicaid members with high clinical needs can lead to lower health care allowed costs. However, the health care industry should adopt a broader framework beyond medical cost reduction when evaluating the returns on addressing HRSNs. Metrics should also reflect nonmonetary values such as improved patient experience, enhanced quality of life, and the potential to reduce health disparities.