CMS Eyes 'Nurture' as Key to Health Costs

— CMS aims to study impact of addressing health-related social, environmental problems

MedpageToday

The Centers for Medicare and Medicaid Services (CMS) wants to know if addressing the social and environmental problems that lead to illness, excessive hospitalization, and death can reduce health spending.

While 95% of healthcare spending focuses on medical services, about 60% of preventable deaths stem from behaviors that can be changed with the right intervention, noted Darshak Sanghavi, MD, and colleagues at CMS in an article published online Tuesday in the New England Journal of Medicine.

The idea of social factors impacting health outcomes is not new, but the concept of the government measuring the effectiveness of these interventions through a 5-year $157 million experiment may be. The payment models that are being piloted are known as accountable health communities (AHC) and are funded by CMS's Innovation Center.

"We're bringing a high degree of scientific rigor to testing these models," Sanghavi told MedPage Today.

"That's very important, because ultimately we need to make the case for our partners -- accountable care organizations, managed care organizations, county health departments or even public partners -- that this whole strategy actually does make sense financially," he added. A press representative for CMS was present during the phone interview.

The crux of the AHC model is its focus on health-related social issues: both the kindergartner whose asthma is triggered by the pests in his apartment, and the senior with diabetes who cannot afford to heat her home and buy meals. Both scenarios not only impede individuals from achieving their best health, but can also lead to excessive, preventable hospital use.

The program's stated goal is to "assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community dwelling Medicare and Medicaid beneficiaries."

The new payment model uses "comprehensive universal screening" to identify patients' health-related social and environmental challenges -- such as homelessness, exposure to violence, and food insecurity.

"It essentially gives you a diagnostic snapshot of their entire social situation," Sanghavi explained.

The initiative was inspired by groups including Hennepin Health, an accountable care organization in Minnesota, which saw a 9% drop in emergency department visits after bringing in housing and community service specialists; Vermont's Blueprint for Health; and coordinated care organizations in Oregon.

The challenge is that what works in Hennepin County might not work in Tallahassee, Sanghavi said.

"We're looking at three very clearly defined tracks, doing a very clear ... test of all of these different interventions to see what can be replicated at a much larger scale."

The program employs a three-tiered system of "awareness, assistance and alignment" to help clinicians link patients to social service and community-based organizations.

In the "awareness" track, patients receive basic referrals. In the "assistance" track, patients are assigned to a navigator for 6 months who helps them to locate important resources.

The "alignment" track includes the same interventions as the lower tracks, but also includes a "backbone" organization -- comprising representatives from health departments, housing, and other community based groups -- that meets regularly and invests in initiatives to target the communities' problems. These challenges could include everything from housing insecurity to problems accessing dental care.

To assess each intervention's impact, the program will randomize beneficiaries to certain services and in some cases use matched comparison groups or matched comparison communities.

"We'll know to a very high degree of certainty whether our intervention, and specifically what aspects of an intervention, actually had an impact," Sanghavi added.

In total, 44 sites will be granted awards through the initiative across the country. The three tiers of "awareness, assistance and alignment" will allow communities to customize their level of integration and the breadth of the initiative will enable CMS to test each model's replicability in different settings.

For example, the track 1 path will be implemented in 15 geographically diverse communities, Sanghavi said.

If that track succeeds, he continued, "As a payer, we can say we know that in 15 different large communities with hundreds and thousands of Medicare and Medicaid beneficiaries, this was a durable and stable way to address these types of needs."

Sanghavi underscored that the agency's role is not to "micro-manage" but to build the broad-based structure and let communities do the rest.

"Our question is, does this broad-based payment strategy and this general delivery system work in 44 different areas?" he said. "If it works, then we'll have our answer."

The application period for participants begins today and runs until April. CMS aims to announce the awardees in the fall of 2016, and to begin the demonstration in early 2017.