Big Step Toward Integrated Care: Medicare's New Payments to Address Social Needs

Carly Roman contributed to this post.

The federal Centers for Medicare and Medicaid Services implemented an important expansion of Medicare benefits this month: Health practitioners may now bill for services that address the health-related social needs of their patients.

At Archstone Foundation, we are enthusiastic about this change, because we view paying for these services as an important step toward achieving equitable, coordinated care that effectively integrates medical care and social care.

Since the start of the year, physicians and other health practitioners have had access to these new billing codes:

• Community Health Integration Services. For patients with unmet needs rooted in social determinants of health, practitioners may bill for the services of auxiliary personnel who play important roles in helping patients access healthcare – among them community health workers, care navigators, and peer support specialists.
• Principal Illness Navigation Services. For patients with serious, high-risk conditions, these codes facilitate billing for auxiliary personnel including care navigators.
• Social Determinants of Health Risk Assessment. Providers may bill for this as part of initiating evaluation and management visits and every six months thereafter. The assessment screens for such health-related social factors as food insecurity, transportation insecurity, housing insecurity, and unreliable access to public utilities.

Learn more from Medicare here.

The new Community Health Integration and Principal Illness Navigation coverage should expand the use of auxiliary personnel to provide such services as help with SNAP or Medicaid enrollment, referrals to emergency food assistance programs, home delivery of meals, and social care navigation.

And the expansion also allows payments to providers who contract with community care hubs and community-based organizations to address the health-related social needs of Medicare beneficiaries, including training of their caregivers. The codes are the first that specifically permit payments when such services are provided by community health workers, care navigators, and others employed by community care hubs or community-based organizations under the “general supervision” of the billing practitioner.

More Person Centeredness

As strong proponents of person-centered care, we applaud the new coverage of assessments to identify patient needs, goals, preferences, and desired outcomes – while also considering individuals’ life stories, cultures, languages, and unaddressed social determinants of health.

Treatment plans are more successful when patients direct their own care and have support tailored to their needs – including referrals to community-based services that can address needs for housing, transportation, and food. These plans should also include educating patients and caregivers in how to participate in medical decisions and understand the role social factors play in health and well-being. Finally, patients may need social and emotional support while making behavioral changes and incorporating treatment plans in their daily routines.

Beyond traditional medical care, care team members with expertise providing social services and health care navigation play a critical role in equipping patients to achieve their treatment goals.

Expanded Social Care Billing

Community care hubs, community-based organizations, and other social service providers can benefit from the new Medicare improvements – but only if billing practitioners contract with them. Notably, patients must give verbal or written consent to the billing provider for the new Community Health Integration and Principal Illness Navigation services, and contracted organizations need to sufficiently integrate their clinical documentation into the records of billing providers. This relieves providers from the administrative burden of directly managing and administering services to meet health-related social needs.

A good example of these hubs is the Partners at Home Community Care Hub. Organized by Partners in Care Foundation, a longtime Archstone Foundation grantee, it brings together community-based organizations throughout California that provide person-centered social services.

Recognizing the importance of learning from those already integrating health and social care, the federal Administration for Community Living is promoting several technical assistance opportunities this year. These include the Community Care Hub National Learning Community, for existing and emerging hubs with health care contracting capacity, and the Housing and Services Partnership Accelerator, which support teams coordinating across organizations to provide services and resources that help people find (and keep) stable housing.

And the Partnership to Align Social Care, also led by Partners in Care and funded by the Robert Wood Johnson Foundation, attempts to lower barriers to coordinated care by guiding providers through the contracting process.

A Glimpse of Reimagined Care Teams

Medicare’s changes are an important recognition by the national government that social services are critical to improving health outcomes. We believe coordinated teams of healthcare and social service providers are the best way to care for older Californians – and that is even more true now that Medicare has enhanced compensation for such teams.

But the success of that enhancement will rely on physicians learning about and then using the new codes. It will require completing new legal agreements to allow collaboration, which may be a significant challenge. The available pay rate to cover the cost of services remains another concern.

Finally, while many providers may be interested in providing Community Health Integration benefits to their patients, only one provider per beneficiary can file a claim for reimbursement each month. If claims are denied only because another provider filed a claim first, well-intentioned providers may be deterred from providing the new integration and navigation services. We believe the use community care hubs is the best way to streamline the process regardless of which practitioner bills Medicare.

The success of these changes, ultimately, will require practitioners to embrace them. And it will require community-based organizations providing Community Health Integration and Principal Illness Navigation services to form strong connections with those providers – and then receive adequate reimbursement for their services.