LABUN:
Welcome to Episode 10 in our series of short explainers for the Hunger Vital Sign tool. Over the next three episodes, we’ll be looking at one of the places that Hunger Vital Sign appears nationally – as part of the Accountable Health Communities Model. For this section we have a new guest expert walking us through the details:
VERLANDER:
My name is Katherine Verlander and I am the Deputy Division Director for a Division in the CMS Innovation Center that houses the Accountable Health Communities model.
LABUN:
As we discussed in the introductory episode, the Accountable Health Communities Model will help us answer questions around using Hunger Vital Sign in the context of other social risk factors for health, and in the context of systems that integrate screening plus next steps to connect patients with resources. This conversation will also provide insight into earlier questions about how a tool like Hunger Vital Sign might become a standard part of health care practice.
First, let’s clarify a few terms.
Accountable Health Communities Model and Accountable Communities for Health are two different things. Don’t blame me, I’m not in charge of nomenclature.
VERLANDER:
Accountable health communities are consortiums led by what we call bridge organization that is participating in the CMS innovation center model test. Accountable communities for health is a broader term. And it includes partnerships doing similar work where they're bringing together cross-sector stakeholders to address health related social needs at a patient level, and also trying to address social determinants at a community level.
LABUN:
We’re looking at the specific Accountable Health Communities Model in this series. And who created that model? That will take some explaining. It begins with CMS.
VERLANDER:
The Centers for Medicare and Medicaid services, or CMS is a federal agency in the U.S. Department of Health and Human Services.
LABUN:
If you’re wondering where the second M went when Centers for Medicare and Medicaid Services became CMS, try saying the acronym with both M’s out loud. If you can, then your diction is impressive and I invite you to host a podcast.
VERLANDER:
We administer the Medicare program and we also work in partnership with state governments to administer Medicaid, and the children's health insurance program. So, Medicare is a health insurance program fully funded by the federal government and it's for people 65 or older, or people under age 65 with certain disabilities, as well as people of all ages with end stage renal disease. Medicaid provides health coverage to millions of Americans, including eligible low income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by the states according to federal requirements. And the program is jointly funded by states and the federal government.
LABUN:
Health care and health insurance are heavily regulated fields. Medicare and Medicaid are examples of programs where the federal government is also the payer, either entirely – like in traditional Medicare – or partially - like in Medicaid. The federal share of Medicaid varies by state, but it’s always at least 50%. And when we look at types of health insurance, employment based is the most common form, followed by Medicare and Medicaid, each at around 18% of the market. These are numbers from just before the pandemic. The show notes will link current National Health Expenditure data.
So, we have this structure of two large health care programs and federal government with a multi-trillion-dollar stake in the outcomes, in addition to the public good interest of supporting the overall health of the country. And we know the system isn’t perfect.
Further complicating things is that when we say “federal government”, it’s not like that’s an individual person. Congress sets statutes that define the programs, while executive branch departments like Health and Human Services interpret and implement the statutes.
How, then, can we make improvements?
VERLANDER:
In 2010, the affordable care act or the ACA created the center for Medicare and Medicaid innovation or the innovation center, the goal of the innovation center is to create a more value-based system that reduces spending while preserving or enhancing quality of care. In establishing the CMS innovation center. Congress recognized the need for innovations in payment and care delivery that address the two most pressing problems facing the us health system at the time: lower than acceptable quality of care and ever-increasing spending that was, and continues to be today, a growing burden on households, states, and the federal government. So Congress gave the innovation center unique authorities to test and expand models.
LABUN:
These authorities lay out the rules for changing from the systems currently in place and describe the conditions under which the Secretary of Health and Human Services can change those systems.
We’re not going to go deep into the theories of health care payment reform. The short version is that CMS wants to match the framework for reimbursement to larger health goals.
We see this blend of economics and social goals in other sectors too. Think about organic food. The social goal for agriculture, written in statute, is to “foster cycling of resources, promote ecological balance, and conserve biodiversity.” An economic mechanism to promote that goal is organic certification. Certification translates into reimbursement through incentives like a label that commands a higher price in the retail market or the ability to get certain contracts only open to organic producers. And there’s a lot of policy debate around what that certification should or should not allow, or what other labels maybe should exist to communicate different standards.
You could also ask if certification for an organic label is the best strategy to reach the state goals. What about something more like the appellation of origin in Europe? Where every region establishes designations reflecting regional priorities – maybe the water supply in Arizona, or re-purposing building lots in a metropolitan space – and the federal government protects the integrity of those regional systems, but doesn’t set standards at the individual producer level. Or maybe we should reconfigure our production subsidies so that consumers don’t need to pay a premium for food that maintains ecological balance, the extra cost of ecology was taken care of further up the supply chain. Or something else entirely.
Here's how we can summarize the process of adjusting payment to achieve goals for the greater public good in health care through the CMS Innovation Center:
VERLANDER:
Essentially, we try new ways to reward doctors for putting quality and the value of your care above how many services they provide or the number of patients that they see.
LABUN:
That’s the brief for the Innovation Center. And as for the characteristics of the different models they test
VERLANDER:
The innovation center develops new payment and service delivery models in accordance with the requirements laid out in our statute. Innovation model tests can focus on specific health conditions or on specific medical procedures like hip and knee replacements. They can also focus on the way a type of provider is paid like a primary care provider. They can also focus on coordination and integration of care models. Tests usually last for a set amount of time. And in some cases only in specific areas or states. They're always evaluated. And if a model shows that it improves the quality of care, or saves money while maintaining quality, we can extend the model and make it available to more patients across the country.
LABUN:
An example of a past successful model was in diabetes prevention.
VERLANDER:
The Medicare diabetes prevention program expanded model is a structured behavior change intervention that aims to prevent the onset of type two diabetes among Medicare beneficiaries with an indication of prediabetes.
LABUN:
We’ll link the Diabetes Prevention Program Expanded Model from the show notes, where you’ll see that it answers a lot of questions about how to set up a lifestyle change based medical treatment in a way that payers can trust it has a reliable track record for producing the desired health results at a known price. Questions like how long does the treatment last, how much of a change is needed to see improved clinical outcomes, and are there certain patient groups it works for better than others – for example, this is recommended for patients with an indication of pre-diabetes while other programs may target earlier stage prevention, before that diagnosis.
VERLANDER:
So the clinical intervention consists of a minimum of 16 intensive core sessions of a centers for disease control prevention approved curriculum furnished over six months in a group based classroom style setting that provides practical training and long-term dietary change, increased physical activity and behavior change strategies for weight control. After completing the core sessions, less intensive follow up meetings furnished monthly help ensure that the participants maintain healthy behaviors. The primary goal of the expanded model is at least 5% weight loss by participants. The national diabetes prevention program is based on the results of the diabetes prevention program study funded by the NIH or the national institutes of health. The study found that lifestyle changes resulted in modest weight loss, sharply reduced the development of type two diabetes in people with high risk for the disease.
LABUN:
The Accountable Health Communities Model was set up to test the following concept:
VERLANDER:
Launched in 2017, the Accountable Health Communities Model addressed a critical gap between clinical care and community services in the healthcare delivery system. And so we're testing whether systematically identifying and addressing health related social needs of Medicare and Medicaid beneficiaries will impact their healthcare costs and reduce avoidable healthcare utilization.
LABUN:
This premise should sound familiar – it’s a variation on the Hunger Vital Sign observation that while clinical tests revealed risk factors like high blood pressure or cholesterol, a lot of health is determined by invisible external factors, like access to nutritious food. Hunger Vital Sign researchers hypothesized that Identifying those invisible risks so that they could be addressed would lead to better health for patients over their lifetime.
Because you’re listening to a podcast series on social risk screening, you can already guess that the ‘identify’ part is going to involve a screening tool. The ‘address’ part of the AHC Model came through two paths, either referrals to community resources or navigation, which combined referral with additional services to help higher risk patients navigate their options.
VERLANDER:
In addition to providing a community referral summary for anyone that screens positive with a need, bridge organizations were also responsible to coordinate and connect beneficiaries to community service providers through what we call community service navigation. And this was for beneficiaries who reported at least one core health related social need and at least two emergency department visits in the last 12 months before screening.
LABUN:
The organization that received the AHC grant and was in charge of setting up the screening, referral, and navigation system was called a Bridge Organization. Many different types of organizations were encouraged to apply for this role – and 32 grantees were selected in 2017.
VERLANDER:
They could be community-based organizations, healthcare practices, hospitals, and health systems, institutions of higher education, local government entities, tribal organizations, or for profit or not for profit, local and national entities. Anyone with the capacity to develop and maintain relationships with clinical delivery sites and community service providers in their community, all AHC bridge organizations are responsible for carrying out the individual screening and referral for social needs, as well as ensuring navigator follow up for high-risk beneficiaries. Bridge organizations also use data to drive quality improvement in implementing screening referral and navigation.
LABUN:
There were two basic levels of services expected from the Bridge Organization. The Assistance Track provided assistance using existing community resources. The Alignment Track went further into shaping community partnerships and available resources to match patient needs.
VERLANDER:
One of the tracks is called the community alignment track and the bridge organizations, in that part of the model worked to align partners in their communities to optimize community capacity to address health related social needs. And so those bridge organizations in the alignment track also perform an annual gap analysis of the community's needs and available resources. And they convene a multi-sector advisory board that can assess and prioritize community needs. And they also create and implement a quality improvement plan in order to address needs that are identified in the community.
LABUN:
That was a lot of Model building. Here’s a recap of the main points:
· The Accountable Health Communities Model refers to a specific national project run by the CMS Innovation Center.
· The CMS Innovation Center focuses on testing models that can improve health quality and reduce costs for patients enrolled in Medicare and Medicaid.
· The Accountable Health Communities Model is testing the specific process of screening for health-related social needs, then referring to community services and, for higher risk patients, providing comprehensive navigation services.
· The entity receiving the grant and in charge of this process for their community is called a Bridge Organization, and the model included many different types of organizations in that Bridge role.
· The length of time evaluating a model depends on what is being tested – in this case there was background research and model design in 2016-2017, grantees were active for 5 years running their programs, from 2017-2022, and now we’re in the evaluation stage. Preliminary reports are available, and we’ll dive into them in the next episodes. A final evaluation report from CMS is still several years away.
You can find links to materials referenced in this episode from our show notes. Then, check out the next episode where we’ll go into more detail on developing the screening tool.