CMS Tests Influence of Social Needs on Health Solutions

By Susan Kreimer
October 23, 2017

The new model represents a departure from traditional payment formulas that focus on volume of services rather than on clinical outcomes.

Sensing that social needs exert a strong influence on health outcomes, the Centers for Medicare & Medicaid Services is creatively testing this correlation.

In April 2017, CMS’ Accountable Health Communities Model selected 32 organizations for grants that will help bridge the gap between clinical and social services for Medicare and Medicaid beneficiaries, who often struggle with housing instability, food insecurity, utility needs, interpersonal violence and transportation issues.

patrick conway

Patrick Conway

The 32 bridge organizations in the model are diverse, ranging from county governments to hospitals, health departments and universities, and they vary in size, location and beneficiary demographics.

“We know that innovation at the state and community level is essential to improve health outcomes and lower costs,” says Patrick Conway, MD, who spent more than six years as CMS deputy administrator for innovation and quality before becoming president/CEO of Blue Cross Blue Shield of North Carolina on Oct. 1, 2017.

The AHC model represents a departure from traditional payment formulas that focus on volume of services rather than on clinical outcomes. In May, a five-year period began to implement and test the model, which follows two tracks: Assistance and Alignment.

“In this model, we will support community-based innovation to deliver local solutions that address a broader array of health-related needs of people across the country,” Conway adds. “As a practicing pediatrician, I know the power of a model like this to help address the health and social support needs of beneficiaries, and their families and caregivers.”

Presbyterian Healthcare Services in Albuquerque, New Mexico, plans to use most of the $4.5 million grant to employ navigators who will screen patients for social determinants that may impact health. The largest integrated health system in the state hopes to strengthen ties between clinical and social services without duplicating existing programs, says Jason Mitchell, MD, a practicing family physician and chief medical officer.

“It really is a way for clinicians to be more connected and for their patients to get resources that are often outside the purview of traditional health care,” Mitchell says. “I can write a prescription, I can counsel them, and I can take care of their medical needs, but it’s oftentimes hard to resolve some of the social needs.”


The Centers for Medicare & Medicaid Services will implement this model over a five-year period to test service delivery approaches aimed at linking beneficiaries with community services that may address health-related social needs. (i.e., housing instability, food insecurity, utility needs, interpersonal violence and transportation needs):

Assistance Track: Provide community service navigation services to assist high-risk beneficiaries with accessing services to address health-related social needs.

Alignment Track: Encourage partner alignment to ensure that community services are available and responsive to the needs of the beneficiaries.

Source: Centers for Medicare & Medicaid Services

Presbyterian has conducted community-needs assessments in searching for ways to improve the link between various services. Western Connecticut Health Network, which also received a $4.5 million grant, found that the CMS model dovetails nicely with its own purpose.

“Our health system has had a long history of trying to identify community needs,” says Robert J. Carr, MD, the network’s vice president for clinical transformation. “It’s one of our historic missions.”

The network’s three hospitals—in Danbury, New Milford and Norwalk—applied for the CMS grant in collaboration with three hospitals in the Value Care Alliance, and various community service agencies and programs, Carr says. Their goal is to screen 75,000 patients across Connecticut annually in primary care clinics, emergency departments, behavioral health, and labor and delivery units.

Housing and utilities probably are the two most significant social needs, says Elizabeth Smith, MD, vice president of the primary care service line at Allina Health in Minneapolis and St. Paul, Minnesota, a recipient of a $3.57 million grant from CMS.

“We recognized that it’s a challenge for our providers to address some of the health-related social needs when they’re caring for patients,” Smith said. And that makes it worthwhile “to study what will make a difference for these patients.”

An increasing body of evidence demonstrates that social factors play a role in the development of disease and its severity, says Paula Braveman, MD, MPH, a professor of family and community medicine and director of the Center on Social Disparities in Health at the University of California, San Francisco.

“This initiative of CMS marks a watershed event,” Braveman said.

In August, CMS announced it would withdraw funding for a third track because the agency did not receive enough qualified applications. This track was expected to increase beneficiary awareness of available community services through information dissemination and referral. The removal does not change the key elements tested by the AHC model, says Danielle Liss, an external affairs team leader for CMS.

Susan Kreimer is a freelance health writer based in New York. 

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