Main well being authorities have more and more emphasised how non-medical components comparable to socioeconomic standing, training, employment, housing, meals safety, and group assist have an outsized impression on well being outcomes. By some latest U.S. estimates, scientific care accounts for under 20% of county-level variation of well being outcomes in the US, with the social determinants of well being (SDOH) accountable for as a lot as 50%. SDOH at the moment are broadly acknowledged as crucial not solely to bettering particular person well being and inhabitants well being, but in addition to assembly federal well being fairness objectives. But standard fashions of well being care supply nonetheless battle with interventions to impression people’ health-related social wants (HRSN). One cause is that well being plans and well being care suppliers should look to nontraditional partnerships with organizations that haven’t traditionally been a part of the well being care business to satisfy these wants.
We spotlight three tendencies related to partnerships to deal with HRSNs:
- Medicaid and Medicare well being plan initiatives;
- Native and regional information sharing efforts; and
- Threat mitigation in collaborations between well being care suppliers and group companions.
Well being care suppliers and well being plans concerned in any of those tendencies — or trying to develop into concerned — should navigate complicated and interrelated reimbursement, privateness, compliance, and fraud and abuse points. It’s crucial to seek the advice of with counsel when creating new initiatives focusing on the SDOH and HRSNs to make sure authorized considerations are evaluated and addressed.
Medicaid and Medicare Well being Plan Initiatives
The Facilities for Medicare & Medicaid Companies (CMS) have begun to include new instruments to foster “entire particular person” take care of Medicaid and Medicare beneficiaries and have applied insurance policies to encourage and pay for acceptable group partnerships.
Late final yr, CMS printed an informational bulletin discussing alternatives for states to cowl companies and helps to deal with health-related social wants in Medicaid and the Kids’s Well being Insurance coverage Program. Accompanying steering describes the authority for well being plans in a state’s Medicaid managed care supply system to cowl “in lieu of companies” that tackle HRSN. For instance, “in lieu of companies” might tackle housing and the house setting by masking a tenant’s first month’s lease, caregiver respite companies, dwelling remediations, and sobering facilities, and will tackle diet wants by masking diet counseling and home-delivered meals. The bulletin highlights latest CMS approvals in seven states for evidence-based housing and dietary companies designed to mitigate the destructive well being impacts of unmet social wants. For the reason that bulletin was printed, CMS accredited New York’s part 1115 demonstration, which incorporates Medicaid alternatives for New York to deal with HRSN by masking related housing helps, enhanced case administration, diet helps, cooking provides, and personal and public transportation to HRSN companies.
events also needs to seek the advice of CMS’ complete 2021 steering on SDOH alternatives in Medicaid, which trumpets Medicaid’s flexibility whereas cautioning that federal ideas require companies to be offered primarily based on particular person assessments of want, usually making Medicaid the payor of final resort (states should assess all out there private and non-private funding streams earlier than utilizing Medicaid to cowl unmet social wants), and require that companies addressing SDOH be financial and environment friendly. CMS particularly identifies how state Medicaid applications might tackle SDOH via managed care, comparable to by sharing managed care financial savings with Medicaid beneficiaries within the type of extra health-related companies, directing well being plans to implement various fee fashions rewarding enhancements in SDOH, providing incentive funds for well being plans that make investments in SDOH, and utilizing waiver authorities to include SDOH companies into the managed care contract and plan capitation charges. A 2023 CMS rule additionally proposed to make important modifications to Medicaid managed care authorities to cowl “in-lieu of companies,” and its finalization is anticipated later this yr.
A 2023 CMS Remaining Rule for Medicare Benefit (MA) additionally addresses how MA plans might impression the SDOH. Over the past 5 to 10 years, CMS has revised MA rules to give well being plans extra discretion to cowl companies that compensate for bodily impairments, scale back avoidable emergency room visits, and tackle SDOH-related wants for chronically ailing enrollees. In some circumstances, MA plans might provide supplemental advantages masking non-medical companies comparable to home-delivered meals, transportation, pest management, entry to community-sponsored applications, and residential modifications. These modifications have allowed MA plans to take a extra holistic strategy and join enrollees to interventions focusing on social components impacting their well being.
Native and Regional Information Sharing Efforts Implicate Privateness Legal guidelines
Leveraging information is crucial for each well being plans and well being care suppliers to establish and tackle HRSN. Whereas some information could also be out there from public sources comparable to census information and group wants assessments, key info that’s confidential and guarded by privateness legal guidelines is more likely to be managed by well being care organizations, governmental service suppliers, and group companions. Integrating and analyzing this info may be important to quantify the prevalence of points like meals insecurity, housing instability, and transportation boundaries. Integration throughout well being and social service sectors additionally permits a complete view of people’ wants and helps focused interventions to high-risk populations. This makes information partnerships between well being care entities and group organizations particularly crucial.
Efforts to gather and share information associated to SDOH implicate a variety of privateness legal guidelines. On the federal stage, well being care suppliers and plans should navigate the complicated and ever-evolving panorama of legal guidelines such because the Well being Insurance coverage Portability and Accountability Act (HIPAA) and substance-use dysfunction confidentiality regulation (ceaselessly often known as Half 2). Many states additionally impose their very own well being info privateness legal guidelines, which can exceed the flooring set by federal minimal necessities. In some instances, well being care privateness restrictions should be balanced towards an evolving set of federal and state authorized necessities to share well being info, such because the federal info blocking rule and California’s latest statewide information sharing framework. And since SDOH prolong effectively past well being info, different privateness legal guidelines addressing info comparable to training information and social companies information should be thought of. Addressing privateness legal guidelines might contain information use agreements, affected person authorizations, de-identification strategies, and the design of bodily, technical, and administrative safeguards to safe information and appropriately prohibit the sharing of identifiable info.
Threat Mitigation in Collaborations between Well being Care Suppliers and Neighborhood Companions
Well being care suppliers and plans additionally have to collaborate with group companions to deal with HRSN by coordinating care and assets for people served by a number of suppliers and companions (who’re additionally usually excessive utilizers with excessive prices). Collaboration might contain multi-party preparations with companions comparable to housing businesses, meals banks, transportation companies, authorities businesses, and social service organizations.
One authorized problem in creating such partnerships is adherence to well being care fraud and abuse legal guidelines. For instance, the federal Anti-Kickback Statute (AKS) and doctor self-referral regulation (Stark) could also be implicated by any trade of remuneration, together with in-kind companies, between well being care entities and group companions who work with Medicaid and Medicare sufferers.
As well as, Medicare and Medicaid anti-supplementation provisions should be thought of when designing funds to incentivize the usage of well being care companies, together with non-traditional companies. Well being care partnerships should be rigorously designed to suit inside regulatory exceptions and protected harbors to mitigate these dangers.
When addressing HRSN for federal well being care program beneficiaries, threat mitigation might contain leveraging the latest value-based exceptions promulgated by CMS and the Workplace of Inspector Normal for the Division of Well being and Human Companies (OIG). Worth-based exceptions can defend from AKS and Stark legal responsibility sure preparations between companions who’re collectively pursuing value-based functions comparable to coordinating and managing care, bettering high quality of care, and appropriately lowering well being care prices. As with every fraud and abuse difficulty, you will need to seek the advice of authorized counsel and set up strong compliance safeguards.
Payor/Supplier Convergence Weblog Collection
For added assets on the intersection of payor/supplier convergence and the problems that plague insurance coverage and well being corporations, payors, and suppliers, click on right here to learn the opposite articles in our collection.
Foley is right here that will help you navigate the complicated authorized points concerned in addressing the social determinants of well being. To be taught extra, please attain out to the authors, your Foley relationship companion, our Payor/Supplier Convergence Space of Focus, or to our Well being Care Follow Group with any questions.
The publish Well being-Associated Social Wants: Three Developments in Leveraging Neighborhood Partnerships appeared first on Foley & Lardner LLP.
