Physicians’ Broader Vision For The Center For Medicare And Medicaid Innovation's Future: Look Upstream
Medical care, it turns out, doesn’t always lead to better health.
That may sound like a radical statement coming from an organization representing physicians, but we believe it’s time to broaden our notion of health if we want to truly care for the nation’s patients. Instead of just treating and managing illness, we envision a health care system that moves beyond the doctor’s office and supports other crucial patient needs—such as food and housing. We think this common-sense approach—which leads to even higher-quality care at reduced cost with improved outcomes—is shared by doctors across state lines and political persuasions.
We believe that there is an urgent need to account for poverty and other health-related social needs as central to any truly effective health care system. Supporting patients in this way will also help to unburden physicians so that we can deliver more appropriate, patient-centered care. That is the message the Physicians Foundation, which represents physicians of all specialties from every state, put forth in our recent response to the Centers for Medicare and Medicaid Services’ (CMS’s) request for information regarding a “new direction” for the Center for Medicare and Medicaid Innovation (Innovation Center).
Historically, our medical system and innovation environment have too often failed to account for patients’ health-related social needs. When we do not fully consider the reality of patients’ lives, it undermines their health, increases use and cost and contributes to physician frustration and burnout. Now, with a national debate on health care in full swing, we have the opportunity to support adoption of best practices and innovation among states, communities, and physicians to address these social comorbidities in a way that demonstrates a real commitment to a patient- and community-focused health system.
How do we do that?
Those of us on the frontlines of medicine have a few ideas:
- Recognize the impact of poverty and other health-related social needs as a guiding principle for how care is designed and delivered;
- Improve care delivery and reduce regulatory burdens faced by physicians by simplifying and consolidating payment and care delivery models, using the lens of patients’ health-related social needs; and
- Support state-level innovation that incentivizes plans and physicians to meaningfully support beneficiaries with health-related social needs.
Address Poverty As A Guiding Principle To Improve Health
Health-related social needs and associated behaviors drive 70 percent of health outcomes. Thus, to improve health while reducing costs and ease administrative burdens on physicians, we need to address these factors in how we pay for and deliver care. As Dr. Richard “Buz” Cooper’s book, “Poverty and the Myths of Health Care Reform,” explains, federal health policy has historically failed to account for poverty and other health-related social needs, with negative effects on patient health outcomes, medical cost, health equity, and physician empowerment. The Innovation Center’s recent request for guidance in framing a “new direction” represents a critical opportunity to correct these omissions and promote a more complete view of health.
Patients and physicians alike support this more comprehensive perspective. Physicians see first-hand the impact of poverty and health-related social needs on outcomes and cost and believe that addressing these needs will yield even more compassionate, higher-quality care.
Pediatricians, internists, surgeons, and other specialists (in both red and blue states and those in between) have witnessed patients who are forced to make impossible tradeoffs that compromise their health: mothers who must choose to pay for food or a child’s medication and families who delay doctors’ visits because the car broke down. Despite breathtaking advances in medicine, none of the latest cutting-edge research and technology will improve patients’ health if they don’t have safe housing, high-quality food, or heat in winter.
A significant and growing body of literature supports accounting for health-related social needs as a guiding principle in the Innovation Center’s new direction. A study published in December 2016 indicates that addressing patients’ health-related social needs improves LDL cholesterol and blood pressure. Another recent study shows that patients’ participation in the Supplemental Nutrition Assistance Program (food stamps) was associated with lower health care expenditures by approximately $1,400 per patient per year.
We simply cannot hope to improve health outcomes, reduce cost, or empower physicians and patients without accounting for 70 percent of what drives health. We applaud the inclusion of screening and navigation for health-related social needs in the Innovation Center’s Comprehensive Primary Care Plus model as a first step. Building on this, we urge the inclusion of health-related social needs as a guiding design principle for all future Innovation Center payment and care delivery models—and revisions to its current models. By doing so, the Innovation Center would send a powerful signal to the market that the goal is achieving health, not only treating and managing illness.
Simplify Models To Address Physician Burnout
The Innovation Center has developed and tested many promising models, but the market often experiences them as uncoordinated and siloed efforts. The proliferation of models creates complex and burdensome regulatory and reporting requirements that make it harder, not easier, to achieve a person-centered system that delivers health. We know that for every hour physicians spend providing direct clinical care to patients, they spend nearly two additional hours on administrative and regulatory work, which affects patient care and is a significant driver of increasing physician burnout.
In keeping with the CMS call for “Patients Over Paperwork” and a focus on “measures that matter,” we believe that the Innovation Center can reduce complexity and physician burden, and strengthen the innovation landscape, by addressing health-related social needs as a core element across a simpler set of comprehensive models. Care delivery models that address the drivers of health and enable greater alignment between physicians and patients are essential, but most current models fail the Buz Cooper test: They do not recognize or meaningfully address health-related social needs. For example, instead of developing multiple accountable care organization models (for example, specialty, rural, and Medicaid) or separate models addressing patients’ social needs (for example, accountable health communities), all future delivery models should make social needs integral to everything from risk-stratification to cost benchmarks to quality measures.
Physicians are further hampered in providing comprehensive care by financing systems aimed only at treating the presenting condition, instead of incentivizing health and preventive care. We encourage the Innovation Center to design care delivery and payment models that incentivize and enable screening and navigating patients to community resources, support the use of care teams, and enable seamless referrals to and partnerships with community-based service providers. Robust tools, workflows, and processes for addressing health-related social needs in the clinical context have been developed in communities across the country, and we encourage the Innovation Center to consider these best practices in designing future models.
Physicians can be a gateway to the basic resources their patients need to be healthy, yet this role generally goes uncompensated and adds to their administrative burden because the health system is still designed primarily to treat acute illness. In value-based payment schemes, physicians often end up bearing yet greater financial risk (and poor performance on quality measures) when their patients are readmitted or require more complex care because the underlying issue is their social circumstance.
States As Laboratories
Many states have already begun working with physicians in local communities—particularly within the context of their Medicaid programs—to experiment with ways to identify and address the health-related social needs of their beneficiaries. The Medicaid Section 1115 waivers, for example, provide states with considerable flexibility in how they operate their programs, both with respect to the delivery of care and the financing of those services. The Innovation Center would send a powerful signal to the market by prioritizing Section 1115 waivers that address screening patients for unmet social needs, include health-related flexible supports (such as funding for transitional housing), and enable broader care team approaches (such as reimbursing community health workers) without shifting resources away from physician practices that often play a central role in coordination of community services.
Moreover, as Medicaid is increasingly being outsourced at the state level to managed care organizations (MCOs), there is a real opportunity to build health-related social needs into how the MCOs support care, collect data, develop quality measures, and incentivize physicians and other providers to address these needs. There is a risk that Medicaid MCOs perpetuate the status quo by focusing on medical needs only and fail to meaningfully integrate social needs into the delivery system and learn from existing best practices.
To address this, states could make specific health-related social-needs services a required component of MCO contracts with state Medicaid programs. Some states have already used this approach, for example, to successfully incorporate community health workers into clinical settings.
The federal government plays an important role in shaping the health care agenda, and through the Innovation Center it created a mechanism to learn in proximity to the market. The initial work of the Innovation Center may have looked to spark innovation across the country, but the next phase presents opportunities to build on that learning to realize a broader vision of health—one that brings physicians and care teams closer to the realities of their patients’ lives. There is little chance that health reform will achieve sustainable improvement as long as 70 percent of what drives health and cost is missing as a core component of new delivery and payment models.