How CMMI is Addressing Social Determinants of Health, Health Equity

Federal agencies and healthcare stakeholders have a renewed focus on addressing social determinants of health and health-related social needs as the COVID-19 pandemic highlighted the importance of health equity.

The Centers for Medicare and Medicaid Innovation Center (CMMI) has prioritized social determinants of health and health equity for years by designing healthcare payment and service delivery models that focus on social needs and social risk adjustment.

During Xtelligent Healthcare Media’s Social Determinants of Health Summit, Tequila Terry, group director of state innovation and prevention and population health at CMMI, shared how the center continues to address health equity through its Strategy Refresh and Accountable Health Communities model.

CMMI launched its Strategy Refresh in Fall 2021, detailing the center’s vision of a health system that achieves equitable outcomes through high-quality, affordable, person-centered care. The plan consists of five key objectives: drive accountable care, advance health equity, support innovation, address affordability, and partner to achieve system transformation.

“When we designed our new Strategy Refresh, we really wanted to focus on developing new models and modifying existing models to address health equity,” Terry explained. “And we called out specifically the need to address social determinants of health as part of that strategy.”

“If we are focused on increasing our reach and having more equitable reach and participation in our models for not just Medicare enrollees, but Medicaid enrollees and all enrollees that are a part of the CMS programs, we really have to be thinking deliberately about the role that social determinants and health-related social needs play in outcomes for those populations.”

Increasing the number of beneficiaries in underserved communities that receive care under these models and strengthening data collection are also parts of CMMI’s health equity goal, Terry shared.

Payment models can address social determinants of health in various ways, including incorporating screenings and referrals, social risk adjustment, direct funding of social services, community convening, and health equity statements.

“In particular, when I think about health-related social needs screening and referral, one of the key things that comes to mind is the work that we are doing with the Accountable Health Communities,” Terry said. “In that model, awardees use different types of data solutions, workflows, and screening staff to use a screening tool to really understand and support enrollees that are grappling with social needs.”

Although the pandemic exposed a slew of inequities, CMMI was focused on addressing health equity back in 2017 when the center launched the five-year Accountable Health Communities model.

The model focused on investigating the impact of health-related social needs of Medicare, Medicaid, and dual eligible beneficiaries at high risk for preventable utilization. The model tested two approaches.

“First, an Assistance Track that tested the impact of systematic screening and referral for social needs,” Terry explained. “And then the Alignment Track that layers on top of that screening intervention with a data-driven alignment of community resources to close some of the systematic gaps within communities, and really focus on cross-sectoral partnerships, including community service providers, healthcare providers, and state Medicaid agencies.”

Under the model, Bridge Organizations conducted screenings for health-related social needs for Medicare and Medicaid beneficiaries.

The CMS screening tool identified beneficiaries struggling with five core domains of social needs: food insecurity, housing instability, transportation barriers, utility access, and interpersonal violence. The model then provided navigators to help connect individuals with resources in their local communities that could address these needs.

According to Terry, more than one million patients received screenings under the model as of February 2022. Additionally, over a third of those beneficiaries had at least one social need identified and more than 132,000 individuals accepted navigator help and connected with resources. Over 85,000 beneficiaries reported that their social needs were resolved through the navigator.

Early evaluation reports of the model, which wrapped up in April 2022, showed that Medicare fee-for-service beneficiaries particularly benefitted from the model.

Future evaluation reports will expand on the model’s quantitative and qualitative impacts on Medicare and Medicaid beneficiaries and larger community impacts, Terry added.

“From this model, I can say that we’ve learned quite a bit on what it takes to stand up a successful health-related social needs screening, referral, and navigation program across very diverse clinical settings and how to foster collaborative and productive partnerships between clinical and community partners,” Terry stated.

As the model’s primary focus involved screenings, technology played a significant role. Not all healthcare organizations have equal access to technology, but CMMI is committed to helping participants overcome those barriers.

“Our goal is always to work with model participants, to understand where we can be a resource and how that can supplement available resources and technology that they have as they participate in our models,” Terry indicated.

The Accountable Health Communities model is just one piece of CMMI’s strategy to address social determinants of health.

“This is an area that has a tremendous potential for us to engage in,” Terry concluded. “We’re doing a lot of exploration around social determinants and health-related social needs and where we can really be effective, using the authorities that we have to test new healthcare delivery models, to test new payment models so that we can actually start to address some of these needs on behalf of the people we serve.”