Might CMS’s Move on SDOH-Related Payment Prove to Be a Game-Changer for Healthcare?
Could the announcement made this week by the federal Centers for Medicare & Medicaid Services (CMS), around Medicare coverage for social determinants of health (SDOH) elements in the Medicare Advantage program, end up proving to be a game-changer for population health efforts?
As this publication noted in a news report on that day, “On April 1, [CMS] announced that it was changing its polices in the Medicare Advantage program in order to support MA beneficiaries in enhancing their health, including around the social determinants of health (SDOH) elements in health status.
In a press release announced on its website, the agency announced that, “Today, the Centers for Medicare & Medicaid Services (CMS) finalized updates that will take significant steps in continuing the Trump administration’s efforts to increase competition among Medicare Advantage and Part D plans so patients get higher quality care at lower costs. These changes will increase plan choices and benefits, and include important actions to address the opioid crisis.” The press release quoted a statement from CMS Administrator Seema Verma, in which Verma stated that “Today’s changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease. With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that they focus on preventing disease and keeping people healthy,” she added.
As the announcement noted, “ The final policies will further expand opportunities for seniors to choose Medicare Advantage plans that are providing new supplemental benefits tailored to their specific needs. Last year, CMS empowered patients through expanding the definition of health-related supplemental benefits that Medicare Advantage plans could offer to enrollees, where the primary purpose of the benefits are daily maintenance of health. Beginning in 2019, Medicare Advantage plans can now offer supplemental benefits that are not covered under Medicare Parts A or B, if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization. For example, plans may offer adult day health services, and/or in-home support services under the expanded definition of supplemental benefits when they meet these standards.”
As a practical matter, the press release noted, “For 2020, today’s announcement gives chronically ill patients with Medicare Advantage the possibility of accessing a broader range of supplemental benefits that are not necessarily health-related but have a reasonable expectation of improving or maintaining the health or overall function of the enrollees. These benefits can address social determinants of health for beneficiaries with chronic disease. For example, beneficiaries enrolled in a Medicare Advantage plan could now receive meal delivery in more circumstances, transportation for non-medical needs like grocery shopping, and home environment services in order to improve their health or overall function as it relates to their chronic illness. For a patient with asthma, for example, a Medicare Advantage plan could cover home air cleaners and carpet shampooing to reduce irritants that may trigger asthma attacks. For someone with heart disease, a plan could provide heart healthy food or produce. And for someone with diabetes, a plan could provide transportation to a doctor’s appointment, diabetes education program or to see a nutritionist.”
This set of changes might seem minor to some who are looking at this from a distance; but the reality is that, by initiating these changes through the Medicare Advantage program, in which some of the most important innovations have been taking place, CMS may be igniting potential change far beyond the confines of Medicare Advantage, as the programmatic innovations in MA are often copied elsewhere. And this one is potentially quite important.
The reality, as all of the leaders trying to move population health management forward already know, is that so many of the factors that impact the health status of individuals are not purely clinical—not at all. I remember writing an article more than 20 years ago for the health plan executive audience, about advances in care management on behalf of dual-eligibles—individuals eligible for both Medicare and Medicaid.
The reality on the ground is that dual-eligibles are older and poor, and many are quite poor, and/or are navigating life with multiple chronic illnesses. And one of the health plans whose executives I interviewed was a senior leader at a health plan based in Minneapolis; the senior executives of that health plan had given care managers broad discretion in helping their plan members to enhance their health status. I remember that executive sharing with me a story. She told me about a dual-eligible plan member, a frail, elderly lady who lived alone in her house in central Minneapolis. It was determined that she was at high risk for a fall; and as we all know, falls are very often absolutely catastrophic for the frail elderly—both clinically and in terms of lifestyle, as well as financially, because of the tremendous amount of healthcare resources that must be spent on their medical care following any fall. That executive told me simply, “We looked at the situation, and decided to pay for a set of handrails to be built into the walls of her hallway. I think it cost something like eighty-five dollars. Think about the tremendous cost, had this member fallen in her home. It only made sense to pay for the handrails.”
That, essentially, appears to be the strategy that CMS officials are pursuing now in Medicare Advantage. And it’s a smart, practical, future-focused one. As all those pursuing population health are finding, it’s becoming imperative to expand our collective focus far beyond the narrow confines of strictly clinical issues.
And as we also know, the Medicare program has always set the pace for the industry in a number of areas; once Medicare adopts a policy change, it tends to quickly ripple through private health insurance plans. That goes double for broad changes made in Medicare Advantage, which remains a highly watched program, and one whose successes are widely copied—relatively quickly, in fact.
And when one combines all of this with the development of ICD-10-related code sets for social determinants of health factors in patient records, as UnitedHealthcare, the American Medical Association, and other organizations are beginning to pursue, one can easily see how progress could be made, with alacrity, in connecting the identification of SDOH factors with potential actions that could be taken to proactively address rising health risk.
What’s more, all of this work will inevitably involve the need for leadership and proactive management on the part of senior healthcare IT leaders, as all of this work will require strong HIT foundations in order to succeed and prosper.
So a new day is dawning, and it’s one in which, more and more, the social determinants of health will be incorporated into care delivery, care management, and population health management. Honestly, that day couldn’t come soon enough.
