Integrating Social Care into the Delivery of Health Care Moving Upstream to Improve the Nation's Health (2019) / Chapter Skim
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5 Financing Social Care
5 Financing Social Care
Pages 109-136
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From page 109... ...
The chapter concludes with the committee's findings. CURRENT HEALTH AND SOCIAL CARE FINANCING Health Care Spending In 2017, an estimated $3.5 trillion was spent in the United States for health care services, or 18 percent of the U.S.
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"National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth." Health Affairs (Millwood)
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social services sector are less well defined than those for health care. International economic analyses (e.g., among OECD countries)
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fragmented financing for dually eligible beneficiaries, and (5) a lack of administrative capacity for social care providers.
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In addition, Medicaid rules offer health plans additional authority to voluntarily cover additional services (including non-medical services) for Medicaid beneficiaries whenever a health plan determines those services to be of value to the individual, although the cost of the services cannot be factored into the payment rates (42 CFR 438.3)
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From page 114... ...
Notably, various activities, including assessing needs and providing linkages to services that address those needs, such as homelessness and food assistance, can be financed through Medicaid by incorporating these activities in the state's definition of case management and health home services.1 In addition, state plan services relating to home- and community-based long-term services also can incorporate a broad range of non-medical services, such as supportive housing services, employment services, and home modifications. Medicaid Managed Care As of September 2018, 39 states and the District of Columbia, which together cover about two-thirds of all Medicaid beneficiaries, had contracted with managed care organizations (MCOs)
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Four practices can be employed by state Medicaid agencies with their contracted plans to accelerate the integration of social care into the health care setting: (1) using value-based payments to support provider investment in social interventions; (2)
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Still, however, questions remain as to what social care activities can be financed with Medicaid dollars. Machledt states that the regulation encourages Medicaid agencies to financially incentivize health plans to address social risks by allowing certain non-clinical services to be included as covered services when calculating the capitated rate and medical loss ratios (Machledt, 2017)
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. Health Care Payment Reform A second challenge to financing social care integration is the method of provider payment, which can have a substantial dampening or accelerating effect on the integration of social care into the health care setting.
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They can be categorized in the areas of accountable care, service bundles, and comprehensive primary care. The committee found descriptions in the literature of the work of accountable care organizations for commercially insured and Medicare populations to integrate social care into health care settings, but the number and comprehensiveness of those descriptions 3 Public Law 148, 111th Cong.
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From page 119... ...
The most comprehensive Medicaid provider payment reform efforts have been in the area of accountable care, often implemented in tandem with delivery reform waivers. In theory, a group of providers of care to Medicaid beneficiaries, held accountable for population health outcomes, financially incentivized through a reconciliation to a total budget for costs and given the flexibility of new covered services, will spend more time assessing the social needs of their patients and arranging for those needs to be met.
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In keeping with the traditional medical model of health care, neither social care activities (awareness, adjustment, assistance, and alignment) nor social risks and social needs are well documented.
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Another accountability issue centers broadly on outputs and outcomes: For what measures -- both general measures and those related to social care integration -- are providers and plans to be held accountable? Accountability measures, even in the most mature Medicaid accountable care programs, have not been tightly focused; instead, they have included a broad array of measures across several domains with great variety among the states (CHCS, 2017)
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From page 122... ...
In particular, while the complexities of developing comparable outcome measures for health care providers are noted above, the use of outcomes-based contracting for social care organizations is nascent. Even if social services accountability measures can be established and appropriately adjusted for factors beyond the control of providers, the possibility remains that the benefits of a managed care organization or atrisk provider investing in efforts to integrate social care needs will accrue only at a later date or to another party, such as the educational or child welfare systems (Taylor and Nichols, 2018)
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The "braiding and blending" of public sources of funding to pay for prioritized social services creates a local environment where "assistance" and "alignment" activities to social care integration are more likely to happen; for example, it makes sense to screen for housing needs in a health care setting if options for meeting the needs exist and can be accessed (Soper, 2017)
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. Fragmented Financing for Dually Eligible Medicare and Medicaid Beneficiaries A fourth challenge is the fragmented financing for dually eligible Medicare and Medicaid beneficiaries.
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. Programs of All-Inclusive Care for the Elderly The PACE Innovation Act of 2015 established integrated Medicaid and Medicare financing to integrated delivery systems for services to almost exclusively dual-eligible beneficiaries at high risk for nursing home admissions (CMS, 2017c)
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However, financial alignment demonstrations seek to move further than what D-SNPs offer. Financial Alignment Demonstrations The ACA established an office in CMS to focus on the dual-eligible population and develop a set of financial alignment demonstrations, which resulted in joint agreements between CMS, a state Medicaid agency, and participating health plans on the categories of dual-eligible populations to be covered, covered services, payment rates, and accountabilities.
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. Lack of Administrative Capacity for Social Service Providers A final challenge to integrating social care into the health care setting is the administrative capacity of social service providers, which often are key to the delivery of social care.
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o Within existing statutory definitions of health care, state Medicaid programs and their contracted managed care plans and accountable providers are innovating with awareness, adjustment, assistance, and alignment activities to pay for social care in health care settings using state plan amendment uthority and the waiver process. This activity is only begin a ning to scale in some states.
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From page 129... ...
The current shift to alternate payment models led by the Center for Medicare & Medicaid Innovation activities -- articularly p the shift to accountable care organizations -- aligns incentives for the provision of social care. o Just as state Medicaid programs are experimenting with dif ferent covered services definitions, they are innovating with new methods to pay providers, such as through account able care organizations, in part to encourage more social care integration work.
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o Even with good accountability measures, health plans and providers struggle to justify investments when returns are delayed and accrue to collaborators. The lack of continu ous eligibility for Medicaid benefits exacerbates this problem, as does the long-term nature of the returns on investments in ocial care integration and on upstream investment in s p ediatric populations.
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• Capacity building for social care providers o Social service agencies and health care organizations have historically not worked together. The systems of financing social services agencies and of financing health care organiza tions are different.
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2016. Variation in health outcomes: The role of spending on social services, pub lic health, and health care, 2000–09.
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2018. Addressing social determinants of health through Medicaid accountable care organizations.
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2018. Investing in social services as a core strategy for healthcare organizations: Developing the business case.
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2014. Evidence-based policy: Reorganizing social services through accountable care organizations and social impact bonds.
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136 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE Walsh, E
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