Better outcomes, lower costs through community partnerships. That was the message last week when over 150 leaders from across America gathered in our nation’s capital for the National Summit on Health Care and Social Service Integration. Across the country, 385 additional colleagues joined the Summit through a live webcast.
Energy grew throughout the day as speakers and participants spoke honestly about practical and conceptual aspects of integrating health care and social services. Many questions from the audience reflected the same aspirations and concerns that I have heard during discussions with colleagues over the past year. Without doubt, the changes we discussed represent a significant moment in American history, one that is too important to miss.
The meeting was opened by HHS Secretary Azar’s Senior Advisor for Health Reform, Jim Parker, who explained the need to be flexible as we integrate health care and social services. He stated, “Just like every healthcare patient presents differently, every person has unique social service needs.” He also announced ACL's $500,000 prize competition that will help create interoperable referral and analytics solutions that connect individuals to social services and can be scaled across communities.
The audience next heard from Demetrios Kouzoukas, Principal Deputy Administrator for the Centers for Medicare and Medicaid Services and Director of the Center for Medicare. He defined the primary driver for Medicare this way: “Everything we are doing in Medicare is designed…to make sure the patient, or customer, is in charge.” He then went on to explain the importance of coupling social services and health care, particularly for people with chronic conditions.
Following the keynote speeches, several panels and four breakout sessions brought out the array of successes and challenges on the road to health care-social services integration. It’s impossible to recap each presentation in this blog, but some key themes emerged from the day.
First, it was clear that payers, health care providers, and community-based organizations (CBOs) were all in agreement that this integration needs to happen. In fact, in many places across the country, it is well underway. The conversation at this stage is about how we proceed in a way that better aligns efforts across health plans, health systems, and community partners to build capacity and scale integration within and across communities. Dr. Tim Ferris, CEO of Massachusetts General Physicians Organization and leader of an accountable care organization (ACO), commented on the complexity of value-based care with different arrangements across payers. He noted that busy inter-disciplinary care teams prefer to collaborate with one community partner for care management and service coordination instead of many plan-specific care managers. Simplification such as this was a theme that was reiterated throughout the day. Simplification was described in the following contexts: (a) one trusted community lead or “trusted broker,” (b) replicating successful models of integration, (c) straight-forward contracting between health care and CBOs, and (d) simplification through a common assessment instrument and data standards.
The second theme was the need for multi-payer financing of social services in the context of value-based payment. Although everyone was not in agreement about whether CBOs should be expected to assume financial risk over time as their health care partners assume that risk, it was clear that there should be multiple sources of financing in a given community that could support both capacity building and sustainability over time. For example, a Community-Integrated Health Network of CBOs could contract with Medicaid Managed Care Organizations, Medicare Advantage Organizations, and Medicare Accountable Care Organizations all in the same market to provide Social Determinants of Health (SDOH) assessments, case management, and home-and community-based services that address each beneficiary’s social risks. There was also agreement that all payers should have a common community infrastructure they all buy into and rely on. This approach reinforces what is already happening in some markets, where Community Integrated Health Networks that deliver social services through a network of CBOs are contracting with multiple payers.
Third, it was clear that CBOs are partnering with health care at a community, state, and national level. The ability for Community Integrated Health Networks to act as a trusted broker of services through strong local connections is important. It is evident that these networks are increasingly statewide to meet the needs of Medicaid and programs for Medicare and Medicaid dual eligible beneficiaries, although they still maintain the specialized knowledge and connections within local communities. Most recently, these community networks are spanning across states and in some cases being organized by a Management Service Organization that has a single contract at an enterprise level with a large national health plan. As these partnerships mature and replicate, many noted the importance of community-based organizations maintaining their core identities, mission, and local connections.
Summit attendees also discussed five guiding principles regarding health care-social services integration: trust, co-leadership, accountability, sustainability, and innovation. Real-time polling of the audience demonstrated wide agreement on the importance of these principles. The discussion that followed the poll brought up the diverse ways of funding the efforts, and the need for funding to come from many places, not just health care. Another suggestion that will be incorporated into the next version of the principles is that we need to be accountable to the people we serve, and not limit the focus on accountability for performance under a health care contract. The dialog informed important refinements to the five principles, and will help guide our collective efforts moving forward.
ACL Administrator and Assistant Secretary for Aging Lance Robertson chaired a lunchtime panel that included Brad Smith, Director of CMS’s Center for Medicare and Medicaid Innovation, and Dawn Alley, HHS’s Deputy Senior Advisor for Value-based Transformations. They shared their views about SDOH innovation and the ways CMMI models are encouraging the integration of health care and social services. Brad highlighted how the Direct Contracting model is encouraging partnerships with Area Agencies on Aging and Centers for Independent Living in addressing social needs. They also noted the importance of braiding and blending of funds, given the significant federal and state expenditures related to housing, transportation, and nutrition assistance.
The panel on the role of state government in social determinants of health, chaired by ACL’s Principal Deputy Administrator Mary Lazare, revealed the diversity of integration approaches employed by different states. Calder Lynch, Deputy Administrator and Director of the Center for Medicaid and CHIP Services, spoke about the existing opportunities under Medicaid authorities to address SDOH under 1915, 1115 waivers, and Medicaid managed care. The importance of coordination across Medicaid, aging, and disability was discussed. Massachusetts Executive Office of Elder Affairs Secretary Elizabeth Chen described how an 1115 waiver allowed the state to implement Medicaid ACOs with a requirement to collaborate with community-based organizations to prevent health care organizations from transferring the community workforce to their own institutions. She referred to the importance of health care “buying” the existing community based services vs. “building” the capacity in-house, which Dr. Bruce Chernof and Lance Robertson wrote about in a recent Health Affairs blog. Our country has invested for many decades in the social services network, and integrating that network with health care – not building a new solution for each health care organization – makes a lot of sense.
It was exciting to see an action agenda emerge from four break-out sessions and to listen as the closing panel synthesized the critical steps we will need to take to make further progress. Regarding financing social care, a near-term recommended action item was to clarify whether payers can count SDOH case management and services that are incorporated into the healthcare delivery towards the medical portion of the medical loss ratio (MLR) and total cost of care. A related near-term action was to test, and potentially replicate, a multi-payer model for common care management services offered by CBOs or a Community Integrated Health Network, where these care management services could be billed with existing Medicare codes or count in the numerator of an MLR. There was strong agreement on an action to define requirements for Community Integrated Health Networks that could then be tied to state and federal policy levers to encourage ongoing financing of SDOH services delivered through these networks. There was also a desire expressed to build the evidence base on impactful SDOH interventions while replicating the integration of CBOs into health care without requiring randomized controlled trials as a bar for evidence prior to scaling. The sense of urgency and the window of opportunity can best be met by rapid cycle evaluation informing replication and scale of successful integration.
The Summit could not have succeeded without our panel moderators and members. We thank each of them: Melinda Abrams, Dawn Alley, Connie Benton Wolfe, James “Jay” Bulot, Elizabeth Chen, Bruce Chernof, Curtis Cunningham, Melinda Dutton, Timothy Ferris, Mary Lazare, Calder Lynch, Sandy Markwood, Tim McNeill, Andy McMahon, Kevin Moore, Jacob Reider, Walter Saurez, June Simmons, Brad Smith, Jim Vandagrifft, Kathy Vesley, and Ginger Wettingfeld.
The main thought I came away with from the summit was that creativity and determination can overcome any obstacles. As we, together, move further into the integration of social services and health care, let’s respect and preserve our cultures and missions and stay centered on the individuals we’re serving. Many examples during the summit revealed the ways health care and social service networks across America are partnering to take advantage of the current opportunity. They are improving the health of the people they serve, and continuing to carry out their core missions. That is the path forward, and all that needs to change is the scale and pace at which we achieve our common goal.