2023: The Year of Things Happening

If you’re lucky, at some point in your career, you will have that magical moment when you sit back in awe and say, “Holy &^%$! It’s happening! It’s really, and finally, happening!” That moment when something you’ve talked about since the beginning of your career actually happens. And it is amazing.

For me, that’s now.

When I began my career in Washington D.C., we were all beginning to recognize, discuss, and quantify the role of health-related social needs in a person’s health and well-being. A few years on we moved to identifying care coordination as a means to assess need and connect with resources. Today we are finally (finally) implementing care models that pay for the provision of these services with healthcare dollars because they do, without question, affect a person’s health and well-being.

It's incredible!

And it is really, really important that we do all we can to get it right.

Some Background

About two years ago, CMS issued a State Health Official letter describing the numerous existing federal authorities that enable state Medicaid and CHIP programs to address health-related social needs (“HRSNs”). In that letter, CMS identified programs in states across the country, from Washington to Maine to North Carolina, in which states utilized Medicaid and CHIP to identify and address HRSNs. The Healthy Opportunities Pilot in North Carolina is the most extensive of these programs, including establishing a fee schedule for evidence-based interventions within four areas: housing, food insecurity, transportation, and interpersonal violence.

There are now 20 states with pending or approved programs in Medicaid and CHIP designed to address HRSNs. CMS continues to issue guidance on how states can implement these programs, with its most recent guidance from January 4, 2023 (in which the agency discusses how the in lieu of services or setting options can provide enrollees access to health-related social services). I mention this to illustrate two things: first, it’s happening and catching on fast. Second, as is the case, whenever the rubber hits the pavement, and things go from theory to practice – it gets complicated. Hence the regular updates and technical assistance CMS provides through these guidance materials.

The Purpose

That leads me to the purpose of this month’s Letter. First to share with you the excitement and joy I feel to see the launch and dispersion of these delivery models. Second, to share some advice for all stakeholders involved in implementing these programs. If there is anything that I have learned throughout my career in healthcare, when it comes to real change: it is a question of patience, persistence, and practice.

Introducing the Stakeholders

Numerous key stakeholders have critical parts to play in making this all work. They each bring different perspectives, priorities, needs, and capabilities. But let’s be honest, this is the American health system we are talking about, and fragmentation is implicit and pervasive. Mostly, these starkeholders aren’t used to working together, at least not in the way they need to under this new approach to care.

While State Medicaid agencies, managed care organizations (MCOs), and providers have long experience contracting and working together, that isn’t the case for community-based organizations (CBOs). While enrollees may receive services from CBOs, they are unlikely to be used to having their healthcare provider or MCO care manager involved in that process.

As a result, the beginning of these relationships is often slow and awkward, marked by caution and hesitation. State agencies often underestimate the difficulty of building a network of CBOs and contracting with them. It’s significant, and it involves a long-time horizon. Similarly, MCOs often mistakenly assume contracting with CBOs will work like healthcare providers. It doesn’t. As one example, most CBOs do not have to intersect with protected health information, so an MCOs intensive HIPAA privacy and security audit process will definitely not be expected. The bottom line is that CBOs are often overwhelmed by the contracting process with a limited capacity to truly evaluate what such a relationship will mean for their operations. And so, they don’t.

Integrating health-related social needs into the healthcare delivery and payment system is complicated. Expecting anything else is na?ve. The key to this integration is going in with eyes wide open and taking the necessary steps to prepare all stakeholders for future changes.

To that end, I share the top barriers all stakeholders should know and plan for.

Top 3 Barriers

1. CBO Capacity and Capabilities: Most CBOs are small, with limited staff supplemented with volunteers. Many are already operating at capacity based on the staff and volunteers they have. Few CBOs have any experience with the compliance requirements that exist in the healthcare system. Boards and staff have limited capacity and experience with major contract negotiations. Before contracting and implementation begin, they need training, technical assistance, and tools. They also need investment upfront to increase staff.
2. Data sharing/exchange: Few CBOs have the information technology hardware, software, or personnel to support data exchange between payers and providers. However, data exchange is central to these programs. First, referrals for service will almost always happen through technology. In North Carolina, the state is using NCCare360, a platform provided by Unite Us. The referrals must be received and acknowledged and either accepted or rejected. This technology requirement has not always gone well in North Carolina, and some organizations are not participating because of this requirement. Additionally, there are requirements for claims submissions. Not many community-based nonprofits have any experience with submitting claims. Many want to use an invoicing system, which many MCOs are unprepared to use. This is understandable, given that MCOs must report encounter data to states and CMS. Once accepted, referrals have to be completed and closed, and documented using information technology is shared via information exchange. And all this information exchange is subject to state and federal privacy and security requirements, not least of which is HIPAA.
3. Engagement of providers and enrollees: Providers are overwhelmed as it is. A requirement to now assess and refer patients for HRSNs is just one more thing on a to-do list that is never done. Engaging, educating, and recruiting providers to participate is a heavy lift. But it is central to the success of the entire initiative. Enrollees need to be educated and informed about the new benefits, including who is eligible and how it will all work. Setting reasonable and appropriate expectations from the beginning is essential because there will be limitations, and it is necessary that enrollees understand this.

None of this is insurmountable. It can all be addressed if all stakeholders are aware of the barriers, prepared to take the steps needed to remove or mitigate them, and if everyone is persistent and committed to making this work.