COVID-19 and MCO-Community Partnerships to Address Enrollee Social Needs

ABSTRACT

Objectives: Many Medicaid managed care organizations (MCOs) now screen enrollees and connect them to community-based organizations (CBOs) to address unmet social needs. COVID-19 has significantly disrupted health care delivery and overall economic activity in the United States. We examined how partnerships between Medicaid MCOs and CBOs to address social determinants of health have been affected by the pandemic.

Study Design: Guided by questions and recruitment strategies developed with our stakeholder advisory board, we conducted 26 interviews with representatives from all 6 of Kentucky’s Medicaid MCOs.

Methods: In-depth, structured interviews for data collection and iterative content analyses to identify themes.

Results: Several themes emerged, including substantial increases in enrollees’ unmet needs and the demand to find new ways to be responsive, changing funding patterns, disruptions to and evolving modes of communication, and shifting partner relationships. In virtually all areas of impact, COVID-19 has been associated with both negative and positive change.

Conclusions: Unmet social needs associated with the pandemic placed tremendous strain on CBOs, limiting their capacity to sustain some programs and partnerships. Isolation associated with COVID-19 also had wide-ranging effects on service delivery, communication with enrollees and partners, and the ability to maintain relationships. Nonetheless, the pandemic also had some silver linings, including additional resources and flexibility for addressing unmet needs. Federal and state agencies, along with MCO leaders, should carefully evaluate what innovations have been particularly effective during the pandemic and craft new flexibilities into their policies, procedures, and regulations.

Am J Manag Care. 2023;29(3):136-141. https://doi.org/10.37765/ajmc.2023.89328

Takeaway Points

Maintaining effective cross-sector partnerships is critical for addressing health and social needs, particularly among vulnerable populations such as Medicaid enrollees. We conducted qualitative interviews with representatives from all 6 of Kentucky’s Medicaid managed care organizations (MCOs) to explore how their partnerships with community-based organizations have been affected by COVID-19. Interviews suggest that partnerships have evolved in response to changing needs and resources, and continued effectiveness requires ongoing innovation and flexibility.

• COVID-19 has strained already-burdened community partners, affecting their service delivery, communication, and partnerships.
• The twin crises of COVID-19 and racism have offered an unprecedented opportunity for change.
• MCOs should consider maintaining effective COVID-19–related innovations and flexibilities.

Food and housing insecurity, transportation needs, low education and health literacy, and unmet economic and behavioral health needs are common in Medicaid enrollees. Because these deficits affect health outcomes and quality of life,¹ many Medicaid managed care organizations (MCOs) have moved beyond their role as a medical service provider; they now screen for unmet social needs and connect enrollees to community-based organizations (CBOs).^2-4 CBOs have historically served as social service providers in their communities, making them better equipped to address unmet needs.^5-8 Evidence examining the nature of MCO-CBO partnerships is still emerging, and we know even less about how these partnerships may evolve during times of high system stress, such as the COVID-19 pandemic.

COVID-19 has significantly disrupted health care delivery and overall economic activity in the United States.⁹ Recent work by Berkowitz and Basu⁹ found that individuals with pandemic-related income disruption were more likely to report increased unmet social needs. For Medicaid enrollees, the disruption of both care and income exacerbated existing social needs and created new gaps. In addition, sudden job loss associated with the pandemic^10-12 has substantially increased the number of Medicaid enrollees. Thus, COVID-19 has been uniquely stressful on Medicaid populations and the organizations that serve them.

MCO-CBO partnerships are a foundational strategy for addressing enrollee unmet needs. Partnerships can take several different forms, including informal collaboration, referral of enrollees for services, and the exchange of resources through formal contracts. Understanding how COVID-19 has affected partnerships may provide critical insights for strengthening those relationships in the future. COVID-19 has highlighted health disparities and the critical importance of addressing the social determinants that fuel these inequities,^13-15 bringing renewed resolve and additional resources to address enrollee unmet needs. At the same time, the challenges of collaboration between MCOs and CBOs have mounted in the face of remote work and dramatic increases in CBO workloads.¹⁶ This disconnect and strain may make it harder to build trust between organizations, a critical component to sustaining collaborative efforts.^17-19

Medicaid MCOs and their partners play an important role in improving social conditions for vulnerable populations affected by COVID-19. Understanding and strengthening these partnerships may accelerate pandemic recovery.²⁰ We used qualitative methods to examine how Medicaid MCO-CBO partnerships in Kentucky, a state with high Medicaid enrollment,^21,22 have been affected by COVID-19. Kentucky has 6 statewide Medicaid payers serving more than 90% of Medicaid enrollees in urban, rural, and Appalachian communities.²³ The Medicaid population is 54% female and 70% White, with an age distribution typical of many Medicaid programs: 34% aged 18 years or younger, 13% between 19 and 26 years, 26% between 27 and 44 years, 21% between 45 and 64 years, and 7% aged 65 years or older.²⁴

STUDY DATA AND METHODS

Participant Recruitment

Our Stakeholder Advisory Board (SAB)—including representatives from the Kentucky Department for Medicaid Services, Medicaid MCOs, CBOs, and academia, as well as Medicaid enrollees—guided interview question development and participant recruitment efforts. MCO representatives on our SAB were asked to identify key individuals in their organizations who were responsible for addressing enrollees’ unmet social needs and population health. These individuals were separately contacted and recruited for this study.

Data Collection and Analysis

We conducted in-depth, structured interviews with study participants between May 24, 2021, and August 4, 2021. Interviews were facilitated using a semistructured interview guide, audio-recorded, and transcribed verbatim. In this analysis, we focus on questions about the impact of COVID-19 on MCO-CBO partnerships. Questions can be found in the eAppendix (available at ajmc.com).

To analyze interview transcripts, we conducted an iterative content analysis using qualitative descriptive analysis,²⁵ an inductive, low-inference method designed to gain an accurate understanding of a phenomenon in the everyday terms of stakeholders. The first stage of analysis involved open coding,²⁶ with transcripts independently coded by 2 authors (H.S., E.R.), who then met to discuss and reach consensus on the central themes. In this meeting, the authors identified the central COVID-19–related themes of patient needs, programs, resources, communication, and relationships. The second stage of analysis involved focused coding,²⁶ with 2 authors (H.S., E.R.) again independently coding transcripts for subthemes within each of the identified central themes. These authors met again to compare findings and finalize themes and subthemes; they identified negative and positive impacts of COVID-19 within each category. Finally, all authors met to review the themes and subthemes and to select illustrative quotations for each. All analytic decisions were made through discussion until consensus was reached.

RESULTS

Participants

Our final sample included 26 representatives from all 6 MCOs (3-6 participants per MCO). Participants were employed in various roles, including vice presidents, directors, and administrators serving in the areas of population health, behavioral health, case management, or community engagement. The data presented in this paper represent the MCO perspective and do not include the experiences of CBOs or Medicaid enrollees. Subsequent data collection efforts in the project will focus on the experiences of these important stakeholders.

Findings

Interviewees highlighted numerous ways that COVID-19 affected MCO-CBO partnerships’ ability to address enrollees’ unmet social needs (Table).

Patient needs. Almost all MCO interviewees noted the negative impact of increased enrollee social needs (associated with COVID-19) on partnership capacity. The most highlighted unmet needs included housing and food insecurity, employment loss, abuse, mental health challenges, and vaccination deserts. Interviewees noted that increased enrollee needs were particularly challenging for the CBO partners. One participant said, “I felt horrible for CBOs. Talk about going from the frying pan into the fire with just the amount of need that they had.”

Several MCO representatives pointed to the challenge of meeting new needs in an already high-need population. The focus shifted to serving immediate needs rather than the implementation of programs with CBOs that would address the longer-term needs of enrollees. One participant said, “We made all these plans of the types of programs that we were going to pilot for different community organizations. But when the pandemic hit, everyone had to shift their focus to helping out those immediate needs.” MCO representatives noted that housing became a particularly pressing issue at the onset of COVID-19 as the rates of homelessness among enrollees increased.

Most interviewees also highlighted ways that COVID-19 positively affected how enrollee needs were addressed with community partners. CBOs were more willing to come directly to MCOs in seeking assistance to bolster capacity. Previously unserved enrollees were now seeking referrals for help because of the pandemic. Participants also reported that MCOs were more seriously considering unmet patient needs and the importance of enrollee health inequities. As an interviewee observed, “Post COVID-19, there is such a focus now on [inequities]. ‘Oh gosh! There are health inequities? Who knew that?’ Yes, we know, but now everybody has seen that more.” MCO representatives pointed to their increased use of data to understand enrollee health and social needs more granularly to better tailor care for subgroups. Several participants highlighted efforts to increase enrollee internet access, particularly for children trying to access virtual instruction. Interviewees also explained that part of taking patient needs and inequities more seriously meant bringing enrollees into the process of addressing needs. An MCO representative said, “You want people to have agency over their care, and you want them to engage with you. You want them to feel that they’re part of the process.”

Programs. Most interviewees noted that many partnership programs with CBOs were stalled, restricted, or canceled due to COVID-19. A participant stated, “Everyone was virtual, [which] made it harder for the community partners; a lot of their events that they typically would have in person became virtual, if they even happened at all.” However, a positive result of COVID-19 was that MCOs and CBOs partnered to implement new or enhanced programs to meet patient needs in more creative and flexible ways. An interviewee stated, “The best thing ever of COVID-19 is that it elevated all of these issues to a level where plans have the flexibility to do what we needed to do. A lot of times, even if we said, ‘We want to get through to everyone,’ you [could]n’t do that. We’re heavily regulated by CMS.” MCO representatives reported that the urgency to meet needs allowed for accelerated timelines in developing collaborative initiatives. Several MCO representatives pointed to vaccination efforts that engaged CBOs and multiple MCOs as particularly innovative programs. One highlighted their MCO’s partnership with a particular CBO, one with strong relationships to a Spanish-speaking population it served: “[CBO] said, ‘We are able to reach a Spanish-speaking population that nobody else really has access to. If I bring the people, will you bring the vaccine?’ Yes. Deal. We got it. So every time we held a vaccination event with [CBO], we ran out of vaccines because they were so successful.”

Resources. MCO interviewees highlighted the availability of new funding sources for COVID-19–related needs, including state, federal, and Coronavirus Aid, Relief, and Economic Security Act dollars, as a positive impact of the pandemic. However, although COVID-19 funding helped initially, when it ended, it left additional unmet needs. An interviewee noted that enrollee needs have outpaced COVID-19 relief funds: “The funds are drying up. We don’t have a lot of resources because there are so many people in need.” Another MCO representative gave food pantries as an example, noting that several pantries opened early in the pandemic, but eventually closed, despite continued food needs. Interviewees also described how resources were diverted to address COVID-19–related needs, which was particularly challenging for CBOs. One noted, “[Resources for] all of the typical things that CBOs were doing got pulled straight [to] COVID-19. So they are doing so much more than they were in their typical job, which was already difficult, and all this collaboration that we want and need and everybody needs, everybody is just thin on resources.”

COVID-19 also positively affected resource allocation because MCOs invested more in CBOs and did so in ways more tailored to each CBO’s unique needs. An MCO participant explained, “Across the board, what you saw was every health care company really putting more resources into the community, recognizing the strain that [COVID-19] was putting on CBOs.” Interviewees reported using several different mechanisms to allocate additional funds to CBOs. Most commonly, they reported the use of grant funds and direct donations.

Communication. Whereas some MCO representatives reported a lower level of connection between MCOs and CBOs because of the shift to virtual communication, others reported more frequent and efficient communication with CBOs. A participant highlighted the importance of in-person interaction with the following: “It’s the opportunity to just drop in because I’ve got a good relationship with the front office or the executive director, that they can go out to coffee and just talk about how things are going. Using Zoom can feel so impersonal compared [with] just getting together.” Others, however, noted that the move to virtual communication was especially helpful for maintaining relationships across scattered geographic areas. The use of virtual meeting platforms was a quick mechanism for communication with partners and led to more frequent interactions with CBOs. As one participant stated, “If the in-person meeting that one of my reps needed to attend was an hour and a half away from where they live and they normally drive to those coalition meetings, now folks were much more comfortable to just participate virtually, so we can cover more ground without having to cover a lot of ground physically.”

MCO interviewees also highlighted the dual impact of COVID-19 on communication with enrollees. Some MCOs adapted how they connected with enrollees by moving toward virtual education sessions and digital platforms for communication. Several MCO representatives discussed the move toward telehealth as a particularly valuable outcome of the pandemic. However, technological barriers also undermined access for some enrollees. As an MCO representative explained, “You need to make sure that the people you’re serving have internet and telephones or broadband or those kinds of things, and unfortunately we live in a state where [those aren’t] always available.”

Relationships. Some interviewees reported that COVID-19 made it much harder for them to build trusting relationships with CBOs. An MCO representative explained, “It has made maintaining relationships harder because it’s not as personal as getting to be face-to-face.” A few MCO participants also reported a limited sense of community connection without in-person interaction. Moreover, several interviewees reported that some CBOs were less responsive because they were stretched thin due to COVID-19 demands. In contrast, some MCO representatives reported that COVID-19 resulted in new or strengthened partnerships. As one interviewee stated, “We’ve all been in this together.”

Despite challenges to relationship building, most interviewees reported efforts to adapt and become more flexible and creative in how they maintained relationships with CBOs because of COVID-19. An MCO participant shared, “Our organizations have found real creative ways to help out in [CBO] communities. And they knew that they could reach out to us as that person to help with that creativity, that we are open to funding innovative ideas, things that haven’t been done before, because we trust them as the subject matter expert and how to help.”

DISCUSSION

Not surprisingly, COVID-19 has had a significant impact on Medicaid MCO-CBO partnerships. Our interviewees highlighted how burgeoning unmet social needs accompanied the pandemic, placing tremendous strain on CBO partners and limiting their capacity to sustain some programs and partnerships. The isolation associated with COVID-19 also had wide-ranging effects on service delivery, communication with enrollees and partners, and the ability to maintain relationships. Nonetheless, the pandemic also had some silver linings, including additional resources and flexibility for addressing unmet needs. We learned that some collaborations between MCOs and CBOs were actually strengthened through shared experiences and priorities.

Our results highlight several key insights related to MCO-CBO partnerships that may illuminate a path forward to strengthening those relationships in the future. A recurring theme was that partnerships evolved in response to current needs and resources. This evolution is both encouraging and challenging. The changing landscape highlights that partnerships can change relatively rapidly to address current needs and opportunities. Nimbleness is often noted as a key ingredient for effective crisis response.²⁷ On the other hand, shifting partnerships may limit the willingness of organizations to make significant investments in their relationships, limiting their potential effectiveness. This tension implies that there is an optimal level of change that preserves partnerships but also supports the ability of the organizations to adapt.

Our results also suggest that the ability to effectively address unmet social needs requires innovation and flexibility. Several interviewees lamented the relatively strict rules, prepandemic, governing their partnerships. The pandemic was associated with somewhat unexpected freedom to creatively craft solutions to address social needs, particularly when providing support to bolster CBO capacity. Several MCOs noted that sustaining momentum would require recognition that CBOs continue to need resources, and that the health care sector can play a critical role in providing those resources. Although regulatory oversight and organizational policies are designed to ensure financial efficiencies and protect against fraud and abuse, these restrictions also limit the effectiveness of MCO-CBO partnerships. Federal, state, and local agencies, along with MCO leaders, in Kentucky and across the United States, should carefully evaluate what innovations have been particularly effective during the pandemic and incorporate new flexibilities into their policies, procedures, and regulations.

Finally, it was evident in the interviews that COVID-19 has not been the only crisis facing MCO-CBO partnerships in the past 2 years. Many would argue that the United States is experiencing at least 2 crises: COVID-19 and persistent systemic racism.²⁸ In the spirit of “never waste a crisis, much less 2 related crises,” MCOs and CBOs have had the unprecedented opportunity to address the systemic inequities and the associated disparities in health outcomes experienced by the populations they serve. MCOs highlighted the importance of continuing to track outcomes in minority enrollees as a mechanism to tailor care and identify community-level initiatives and CBOs that they might prioritize to address needs. Education access and attainment as a powerful determinant of health and social outcomes was also discussed as an important area for MCOs to prioritize as they address inequities. Although the relationship between unmet social needs and health disparities is not new, the intense spotlight is new, and it is having a beneficial effect. So how can we sustain this momentum? Future research examining how MCOs continue to prioritize initiatives addressing enrollee inequities can be used to track changes.

There are promising developments at the federal level that may support ongoing efforts to maintain focus and impetus. The National Institutes of Health Strategic Plan identifies understanding the social determinants of health as a key priority for foundational science and reducing health disparities as an operational focus.²⁹ Both foci have the potential to increase our understanding of effective policies and programs that address social needs to improve health outcomes. The Center for Medicare and Medicaid Innovation, a key organization for driving innovation and change throughout the health care system, recently announced a significant new focus on health equity.30 This lens promises additional attention, innovation, and flexibilities for Medicaid programs as they partner with CBOs to address unmet social needs.

Limitations

Our study had several limitations. First, participant perspectives may not necessarily be representative of their MCOs or the geographic region, and an examination of meaningful variation in perspectives by organization or region was beyond the scope of this research. It is also important to note that the data collection occurred approximately 1 year after COVID-19 began to affect MCO-CBO work, and views may have evolved over the arc of COVID-19. In addition, we did not examine the level of formality in partnership arrangements. Finally, the data presented here represent the MCO perspective; as such, they do not address the effectiveness of partnerships or interventions and do not include CBO or Medicaid enrollee experiences. As mentioned previously, subsequent efforts in this project will focus on their experiences.

CONCLUSIONS

The COVID-19 pandemic has underscored the importance of addressing health-related social needs. Making progress on the upstream determinants is not something that can be accomplished by a single organization. Building strong and effective partnerships is a critical component in addressing health and social needs, particularly among vulnerable populations like Medicaid enrollees. Although our results highlighted challenges presented to Medicaid MCO and CBO relationships by COVID-19, we also found remarkable resilience, flexibility, and growing appreciation for the role CBOs play in addressing enrollee needs.

Acknowledgments

The authors would like to thank the Study Advisory Board members for their help in guiding the research.

Author Affiliations: Department of Health Management and Policy, College of Public Health, University of Kentucky (RH-G, ER, ERC, TMW), Lexington, KY; Department of Communication, College of Communication and Information, University of Kentucky (AMS, HS), Lexington, KY.

Source of Funding: This research was supported by a grant from the Robert Wood Johnson Foundation as part of the Research in Transforming Health and Health Systems Program (Grant ID 77256). Research reported in this publication was also supported by the Kentucky Cabinet for Health and Family Services, Department for Medicaid Services, under Agreement C2517 titled “Medicaid Managed Care Organizational Strategies to Address Enrollee Unmet Social Needs.” The content is solely the responsibility of the authors and does not necessarily represent the official views of the Cabinet for Health and Family Services, Department for Medicaid Services.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RH-G, AMS, HS, TMW); acquisition of data (RH-G, AMS, TMW); analysis and interpretation of data (RH-G, AMS, HS, ER, TMW); drafting of the manuscript (RH-G, AMS, ER, ERC, TMW); critical revision of the manuscript for important intellectual content (RH-G, AMS, HS, ER, TMW); provision of patients or study materials (HS, ERC); obtaining funding (RH-G, TMW); administrative, technical, or logistic support (RH-G, ERC, TMW); and supervision (RH-G).

Address Correspondence to: Rachel Hogg-Graham, DrPH, College of Public Health, University of Kentucky, 111 Washington Ave, 107B, Lexington, KY 40536. Email: Rachel.hogg@uky.edu.

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