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CMS exploring models centered on social health factors

May 11, 2023

Regulators said they’re trying to work around restrictions regarding what groups Medicare is allowed to pay as they look to address social determinants of health.

The CMS is exploring programs that would pay social or community health workers to address patients’ social needs in a bid to invest more heavily in food, housing, transportation and other social determinants of health, according to agency officials.

"We are looking at that. For example, in maternal health, thinking about the role of doula and community health workers," Liz Fowler, director of the Center for Medicare and Medicaid Innovation, said on Thursday during the CMS’ inaugural health equity conference.

Social determinants of health are a significant driver of health outcomes and medical costs, especially for vulnerable populations. Despite widespread acknowledgment of the importance of addressing SDOH, investments tend to be modestly funded or temporary, and stalled during the COVID-19 pandemic, data shows.

The cost for primary care practices to screen patients for social needs is substantial, but pales in comparison to the cost of interventions, according to one recent study.

The study estimated that existing federal funding covers less than half of the cost of providing food, housing, transportation and care coordination assistance.

Advocates have been calling for greater investment in the nation's underfunded social care programs, to address downstream factors that result in poor health outcomes. Though it might seem backward for healthcare programs to address things like food or housing insecurity, the reality is that they have more money to spend, Fowler said.

However, legal requirements stipulating who Medicare is allowed to pay — essentially, traditional healthcare providers — can hamstring the creation of more social-focused programs, said Meena Seshamani, CMS Medicare director.

As a result, regulators in the Biden administration are trying to find ways to expand or work around those restrictions. A new CMMI model announced Thursday gives funding to primary care physicians, but encourages them to use it to contract with a community-based organization, Seshamani said.

"We’re also exploring, particularly in our accountable care organizations — traditionally, you had to see a primary care physician to become part of one of these models. And we’re thinking about, what about nurse practitioners? What about a social worker? Are there other people who are involved in someone's care on a regular basis where it would make sense to say, OK, that becomes the hub for these models?" Seshamani said.

CMS officials made their case for fundamentally changing healthcare programs like Medicare to refocus around health equity — a key priority for the Biden administration — at the conference this week.

The CMMI, created by the Affordable Care Act, tests new payment models to try to push the industry toward more value-based care. The agency, which receives $10 billion every decade to invest in new models, paused or ended a number of models a few years ago following watchdog and congressional criticism that few models to date have resulted in cost savings or better care quality.

Since then, the CMMI has realigned its models, which touch tens of millions of Americans, to focus more heavily on accountable care and health equity.

Now, all of CMMI's models require providers to collect social determinants of health data. The CMMI has also committed to include patient-reported outcomes measures in all of its models, and is currently looking at other factors it can incorporate to accurately capture disparities, Fowler said.

For example, regulators currently define underservedness based on dual-eligibility status and area deprivation index, but are considering including other factors like life expectancy, Fowler said.

The CMS is also working to align internal metrics around health equity. Currently, different Medicare programs in fee-for-service and Medicare Advantage have their own set of measures.

"It presents a really good opportunity to become more granular with these measures, so that we can really see across different types of people how are things being done, so that you can really drive equity in everything," Seshamani said.

The CMS is also working to expand a CMMI concept allowing providers from rural and underserved communities to apply for upfront funding to invest in health-related social needs to the Medicare Shared Savings Program, Seshamani said.