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JAMA Forum
December 16, 2021

Promoting Health Equity by Paying for Social Care

Author Affiliations
  • 1Department of Social Work and Community Health, Rush University Medical Center, Chicago, Illinois
  • 2Center for Health Policy and Media Engagement, George Washington University School of Nursing, Washington, DC
JAMA Health Forum. 2021;2(12):e215023. doi:10.1001/jamahealthforum.2021.5023

Two major reports from the National Academies of Science, Engineering, and Medicine (NASEM) in 2019 and 2021 have called for clinicians, health care systems, and society to foster health equity by integrating social care into health care delivery and partnering with communities to address social determinants of health.1,2 However, good intentions by clinicians and systems are stymied by payment restrictions and the outright lack of payment for social interventions that may improve health and reduce costs.

Integrating Health Care and Social Services

In 2011, researchers addressed the paradox of the US leading peer countries in health care spending per capita but having poorer health outcomes.3 Their analysis of 30 countries found that those with a higher ratio of spending on social services to health care services had better outcomes in infant mortality, life expectancy, and potential life years lost.

Subsequent research showed that US states with higher ratios of spending on social services and public health to spending on health care (Medicare and Medicaid) have significantly better outcomes in key domains, including adult obesity, mentally unhealthy days, and days with activity limitations.4 Furthermore, intentional integration of health care and social services is associated with improved health and lower costs, according to a 2016 analysis, with 32 of 39 studies reporting better health outcomes, health care costs, or both. The greatest benefits were seen in housing support, income support, food insecurity, and care coordination.5

The evidence is clear and growing, prompting insurers such as UnitedHealth Group to partner with communities to build housing because it lowers medical expenditures. Other health care organizations are implementing strategies to address social risks and social needs for patients, families, caregivers, and communities. As framed by a model included in both NASEM reports, these organizations are increasing awareness about social risk factors and social needs, adjusting care based on this awareness, helping address needs, aligning health care resources with community priorities and assets, and advocating for more social resources to improve community health and well-being. However, this is not yet happening at the scale needed to make a difference in deep inequities in the US.

Payment Reforms

The 2 NASEM reports call for payment reform to provide clinicians and organizations maximum flexibility in addressing the health and social care needs of individuals and communities.

Value-based care initiatives and demonstration projects under the Centers for Medicare & Medicaid (CMS) provide some flexibility but are not widespread and need further development and evaluation. For example, the accountable health communities model, launched in 2017, funds 28 collaborations to screen for social needs and provide referrals to address these needs. However, CMS provided funding only to hub organizations conducting screening, not to the service providers for their staff, infrastructure, or resources to respond to referrals. Centers for Medicare & Medicaid could have guided organizations to contractually reimburse referral partners and studied the effect of those contractual models, referral partner capacity, and effect on beneficiary health outcomes.

Other payment reforms are needed now. The 2019 NASEM report recommended that CMS clearly define which aspects of social care Medicaid can cover. In January 2021, CMS released guidance to state health officials for Medicaid and the Children’s Health Insurance Program to address social determinants of health. The guidance focuses on services and supports that states can cover under current law, including housing-related services and supports, nonmedical transportation, home-delivered meals, educational services, and employment supports. This guidance was released by a Republican administration; these principles are bipartisan and financially smart. State Medicaid agencies should use these flexibilities to guide health plans and health care and social care providers.

Another recommendation is that CMS should accelerate learning about how integrating health and social care can improve health and reduce health care costs. Despite the Center for Medicare and Medicaid Innovation (CMMI) investing in dozens of impressive population health initiatives in the last decade, there has been little focus on workforce or activities that are effective at addressing social needs among diverse populations. The CMMI recently outlined a new strategic plan for its work ahead, including a focus on equity and assessing the effect of models on underserved populations. As part of this effort, the CMMI should identify social care integration activities and workforce deployment strategies associated with effectively closing gaps in outcomes.

Both reports recommend expanding the workforce capacity to address social risk factors and social needs in alignment with health care, including social workers and registered nurses who are key to care coordination that integrates health and social needs. Although fee-for-service billing codes recognized by Medicare (namely, chronic care management, transitional care management, and behavioral health integration) typically recognize time contributed by social workers and nurses to address barriers to care including social needs, those billing codes rely on a physician or other qualified health professional to initiate and be regularly involved in these services, which has slowed their implementation. Instead of relying on physicians to lead these initiatives, CMS should recognize the full training, education, and scope of practice of social workers and nurses to lead and seek reimbursement for assessing and addressing social needs in partnership with patients and caregivers. This policy change would enable organizations in diverse communities to hire and retain the workforce to conduct this work.

One opportunity for Congress is to recognize the full scope of practice of clinical social workers. Currently, Medicare recognizes clinical social workers only as mental health providers despite their being deployed regularly in social care and discharge planning. This restriction limits social workers from independently billing for health and behavior assessment and intervention services (under Current Procedural Terminology [CPT] codes 96156-96171). Another opportunity to support interprofessional approaches to care management is already described by CPT codes 99366 and 99368, which support activities with 3 or more professionals interfacing with patients and families or having a team care conference on their behalf. However, Medicare does not recognize these codes; changing this policy is a clear opportunity that could enable interprofessional clinicians, including nurses and social workers, to gain recognition for hard-to-bill services such as care coordination, patient assessment, end-of-life counseling, health education, and prevention services.

Payment reform that enables clinicians and organizations to address social barriers to health offers an opportunity to address inequitable health outcomes. As the health care workforce shortage exacerbated by the pandemic worsens, supporting social workers and nurses to address people’s social needs can prevent high-cost, downstream health care and inequitable outcomes.

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Article Information

Correction: This article was corrected December 30, 2021, to add the word “is” to the first sentence in the second to last paragraph.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Ewald B et al. JAMA Health Forum.

Corresponding Author: Diana J. Mason, PhD, RN, Center for Health Policy and Media Engagement, George Washington University School of Nursing, 1919 Pennsylvania Ave NW, Ste 500, Washington, DC 20006 (djmasonrn@gmail.com).

Conflict of Interest Disclosures: Ms Golden and Dr Mason reported serving on the National Academies of Science, Engineering and Medicine (NASEM) committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health that produced the 2019 report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Dr Mason reported writing profiles and case studies for the NASEM report, The Future of Nursing, 2020-2030: Charting a Path to Achieve Health Equity. No other disclosures were reported.

References
1.
National Academies of Science, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Published September 25, 2019. Accessed December 14, 2021. https://www.nationalacademies.org/our-work/integrating-social-needs-care-into-the-delivery-of-health-care-to-improve-the-nations-health
2.
National Academies of Science, Engineering, and Medicine. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Published May 11, 2021. Accessed December 14, 2021. https://nam.edu/publications/the-future-of-nursing-2020-2030/
3.
Bradley  EH, Elkins  BR, Herrin  J, Elbel  B.  Health and social services expenditures: associations with health outcomes.   BMJ Qual Saf. 2011;20(10):826-831. doi:10.1136/bmjqs.2010.048363PubMedGoogle ScholarCrossref
4.
Bradley  EH, Canavan  M, Rogan  E,  et al.  Variation in health outcomes: the role of spending on social services, public health, and health care, 2000-09.   Health Aff (Millwood). 2016;35(5):760-768. doi:10.1377/hlthaff.2015.0814PubMedGoogle ScholarCrossref
5.
Taylor  LA, Tan  AX, Coyle  CE,  et al.  Leveraging the social determinants of health: what works?   PLoS One. 2016;11(8):e0160217. doi:10.1371/journal.pone.0160217PubMedGoogle Scholar
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