Things are evolving forward pretty quickly these days at the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS)—faster than some might believe. One example that comes to mind is CMS’s new pilot project around the social determinants of health for Medicare and Medicaid patients. Announced in January, the new program has the potential to add significantly to federal efforts to enhance health and healthcare for vulnerable populations.
“We recognize that keeping people healthy is about more than what happens inside a doctor’s office, and that’s why, for the first time, we are testing whether screening patients for health-related social needs and connecting them to local community resources like housing and transportation to the doctor will ultimately improve their health and reduce the cost to taxpayers,” HHS Secretary Sylvia M. Burwell said in a statement, as she unveiled on Jan. 5 the Accountable Health Communities model, being supported by the CMS Innovation Center. “The Accountable Health Communities model is yet another step towards building a health care system that results in healthier people and stronger communities and spends our health care dollars more wisely.”
As the HHS/CMS announcement noted, “The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. In taking this approach, the Accountable Health Communities model supports the Center for Medicare & Medicaid Service’s (CMS) ‘better care, smarter spending, and healthier people” approach to improving health care delivery.’”
CMS has created three “tracks” in the program. Track 1, or “Awareness, will “increase beneficiary awareness of available community services through information dissemination and referral”; Track 2, or “Assistance,” will “provide community service navigation services to assist high-risk beneficiaries with accessing services”; and Track 3, or “Alignment, will “encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries.”
Specifically, “CMS will award a total of 44 cooperative agreements ranging from $1 million (per Track 1 site) to $4.5 million (per Track 3 site) to successful applicants to implement the Accountable Health Communities model. Applicants will partner with state Medicaid agencies, clinical delivery sites, and community service providers and are responsible for coordinating community efforts to improve linkage between clinical care and community services.” The agency’s announcement notes that “CMS funds for this model cannot pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, and transportation) received by community-dwelling beneficiaries as a result of their participation in any of the three intervention tracks”; rather, the agency is making clear that award recipients “must use their award monies to fund interventions intended to connect community-dwelling beneficiaries with those offering such community services.” But the programmatic emphasis seems to be in all the right places.
In a commentary published in AJMC.com, the online edition of the American Journal of Managed Care, Laura Joszt noted that “This pilot project from the Centers for Medicare and Medicare Services Innovation Center will place focus on health-related social needs of Medicare and Medicaid beneficiaries.”
Joszt noted that the pilot program will focus on the social determinants of health; recognizes that “health is more than just what happens in the doctor’s office”; “will build alignment between clinical and community-based services so beneficiaries struggling with unmet needs related to their health can be aware of any services that are available in their area and can receive assistance to use them”; will advance the move to value-based care; and will advance “the move to address health equity, vulnerable populations, and healthcare disparities.” Per the shift to value-based care and payment, Joszt noted in her article that “The new model was released almost a full year after HHS announced in 2015 that it was setting a timeline to move healthcare payment for Medicare to a value-based system. Burwell said that the model is a step toward building a system that spends healthcare money more wisely, while improving health of beneficiaries,” Joszt noted.
There are several key things to note here. First, senior federal health officials from HHS/CMS are signaling that they recognize how very important the social determinants of health are, in the health status of covered populations. Second, they are creating a model at the federal level to begin to address those determinants.
And third, there is a great deal of potential here for said federal officials, and the leaders of the patient care organizations that will be participating as grantees in this pilot program, to be able to share their learnings, as the program evolves forward.
Are the leaders of accountable care organizations and other risk-based contracting initiatives in the private sector already learning about some of these issues? Definitely yes. And it’s turning out that incorporating information and insights around the social determinants of health, into population health management and care management initiatives, is a complex endeavor, as the U.S. healthcare system has historically not been set up to consider those determinants. Most care has taken place far downstream, based on acute care- and emergency care-based models.
Moving interventions upstream is inherently challenging in a downstream-driven, volume-driven healthcare system focused on acute illness and on injury. Still, as Joszt noted in her Feb. 5 commentary, “The announcement of the new ACO model followed just months after CMS released a plan to address health equity in Medicare and also proposed protections to reduce discrimination and disparities in healthcare. Addressing social determinants are a way,” she added, “to promote health for vulnerable populations and to achieve health equity, whether it is to improve housing or get low-income individuals access to a supermarket in a food desert.”
And therein lies part of the inherent challenge: how to frame all the social determinants of health, and which ones to address, and in what order and with what methods?
On the IT and data level, there is also a very deep and broad challenge here: right now, patient care organization leaders are struggling simply to move forward beyond basic electronic health record implementation into EHR optimization and broad intra-organizational clinical transformation, let alone to collaborate with payers—federal, state, and private health insurance—to combine clinical and claims data on behalf of identified patient groups, in ACO and population health arrangements. Even those kinds of initiatives are proving to be challenging.
So adding in social determinant factors is going to be a major new steep learning curve to begin to master. And yet, therein lies a huge amount of potential for improving the health—not just the healthcare—of covered populations. It will require the intensive collaboration of clinician, clinical informatics, IT, and other healthcare leaders in order to truly improve the health status of millions of Americans, particularly those with chronic conditions and those who are socioeconomically marginalized (sometimes the same people).
In any case, it will be fascinating to see how this new federal initiative moves forward. And those negative Nancys out there proclaiming loudly that federal health officials never listen or pay attention, should pay close attention to this initiative, as it evolves forward—because its evolution will inevitably say a lot about the ability of the U.S. healthcare system to move forward on a broader level as well.
