Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

CMS, HHS Get Social with $157M in Medicare, Medicaid Funding

"[CMS] will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.”

By Jacqueline DiChiara

- The Department of Health and Human Services (HHS) has revealed a new 5-year $157 million funding opportunity this week to help advance the overall quality and affordability of Medicare and Medicaid. The health-related social needs of Medicare and Medicaid beneficiaries will hopefully no longer continue to be ignored through this funding endeavor. No, not the smartphone-glued-to-the-hands kind of social needs. The generally overlooked or ignored social needs that put patients in the hospital and drive up healthcare costs, that is. 

Accountable Health Communities model healthcare delivery

This Accountable Health Community (AHC) Funding 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,” explains the Centers for Medicare and Medicaid Services (CMS).

“In taking this approach, the [AHC] model supports [CMS’s] ‘better care, smarter spending, and healthier people’ approach to improving health care delivery.”

Healthcare industry still needs to tackle the Medicare/Medicaid social needs gap

Over the course of several decades, the concept of addressing Medicare and Medicaid beneficiaries' social needs has solidifed itself as a viable and ongoing topic of discussion.

Over 95 percent of the trillion dollars spent annually on healthcare funds are focused on medical services, said The New England Journal of Medicine (NEJM) in yesterday's article. But 60 percent of preventable deaths are reportedly tied to malleable behaviors, NEJM asserted.

“Despite calls for obtaining an expanded social history at the point of care, most health care systems lack the infrastructure and incentives to develop comprehensive, systematic screening-and-referral protocols and relationships with the array of community service providers that would be required to address their patients' health-related social needs,” wrote NEJM researchers.

“Most clinicians are familiar with the stories behind these statistics: the child with asthma whose substandard housing triggers repeated emergency department visits; the patient with repeated visits for severe abdominal pain caused by her violent home life; the older adult with diabetes forced to choose between paying for heat and buying groceries.”

"[CMS] will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.”

CMS says chronic conditions are exacerbated when health-related social needs are not met – i.e. food insecurity and unstable housing situations. When a patient cannot sufficiently manage his or her healthcare issues, increased healthcare costs and avoidable healthcare utilization may subsequently develop.

To help rectify this, over a five-year long performance period, CMS will execute a tri-fold model to help achieve various service approaches. Each tier will be linked to a payment method.

CMS’s top 3 targets:

One goal is to increase awareness levels among beneficiaries about available community services. Another objective is to foster greater levels of assistance for high-risk beneficiaries via community service navigation services. A third approach is to help advance partner alignment efforts.

NEJM stated the AHC project’s 3 incremental levels of care delivery allow for greater flexibility, because each can be implemented across a variety of settings.

“The model permits flexibility in each track and incorporates extensive local support and technical assistance to help sites integrate interventions into their workflows,” researchers said.

CMS additionally asserts the AHC model helps advance clinical-community collaboration in 4 specific ways:

  • Screening of community-dwelling beneficiaries to identify certain unmet health-related social needs;
  • Referral of community-dwelling beneficiaries to increase awareness of community services;
  • Provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services; and
  • Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries.


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