HHS SDOH Policy Activity
The U.S. Department of Health and Human Resources (HHS) has increasingly indicated their understanding of the importance of addressing social determinants of health as a way to improve patient’s outcomes and reduce overall costs. Most recently, at a November policy symposium held by the Hatch Foundation and Intermountain Healthcare, HHS Secretary Alex Azar suggested that his agency may begin allowing some federal health programs to directly address social factors.
Among the Administration’s four pillars of focus, Secretary Azar indicated that value-based payment systems would be the ideal starting place for social determinants of health work. Through numerous initiatives and activities among a number of agencies, HHS has indicated their support of federal, state, and local level efforts and policies to address social risk factors.
NASDOH is a group of stakeholders working to systematically and pragmatically build a common understanding of the importance of addressing social needs as part of an overall approach to health improvement. We seek to make a material improvement in the health of individuals and communities and, through multi-sector partnerships within the national system of health, advance holistic, value-based, person-centered health care that can successfully impact the social determinants of health. NASDOH brings together health care, public health and social services expertise, local community experience, community-convening competence, business and financial insight, technology innovation, data and analytics competencies, and policy and advocacy acumen to assess and address current regulatory frameworks, funding environments and opportunities, and practical challenges to implementing and sustaining social determinants of health efforts.
Below we briefly outline the federal agencies NASDOH has identified to date as working on specific social determinants of health activities or initiatives. NASDOH will continue to track and update the list of activities as they become known.
During the Intermountain Healthcare and the Hatch Center for Civility and Solutions symposium on November 14, 2018, U.S. Secretary of Health, Alex Azar, provided remarks on the ongoing Departmental policy efforts to address SDOH. In his remarks, he highlighted the importance of SDOH at HHS as part of their value-based framework, including their work on integrating services and addressing social determinants through several different models at CMMI (Maternal Opioid Misuses (MOM) Model and Integrated Care for Kids Model) and through the Accountable Health Communities model.
Signed into law on February 9, 2018, the Social Impact Partnership to Pay for Results Act (SIPPRA) would fund social programs that achieve real results and redirect funds from ineffective programs to programs with demonstratable results. $100 million in funding is now available for proven models integrating social services and medical services care and must include a state or local partner in its model. This amount will be made available until 2028 (10 years). In addition, the OS-HHS is participating on the Federal Interagency Council on Social Impact Partnerships that is tasked with determining the disposition of the funds. The Commission on Social Impact Partnerships, a private-sector advisory panel, has also been appointed. On February 22nd, 2019, the Notice of Funding Availability was published that invites applications from State and local governments for awards under SIPPRA. On March 28th, 2019, the Commission on Social Impact Partnerships convened for a public meeting (meeting minutes available here).
On July 9, 2019, the Department of Health and Human Services (HHS) announced the formation of the Quality Summit (QS) to convene key industry stakeholders and government leaders to discuss how current quality programs administered by HHS can be better evaluated, adapted, and streamlined to deliver value-based care focused on improving health outcomes for Americans. The Executive Order signed by President Trump on June 24, 2019 directs federal agencies to develop a Health Quality Roadmap that aims to align and improve reporting on data and quality measures across federal health programs.
The Department of Health and Human Services (HHS) announced the “Regulatory Sprint to Coordinated Care” in the summer of 2018 and stated that it is “focused on identifying regulatory requirements or prohibitions that may act as barriers to coordinated care, assessing whether those regulatory provisions are unnecessary obstacles to coordinated care, and issuing guidance or revising regulations to address such obstacles.” CMS and OIG are currently reviewing comments on several RFIs (e.g., RFI on HIPAA) and are expected to issue proposed rules in 2019.
On March 6, 2018, CMS announced the MyHealthEData initiative to empower patients by giving them control of their health care data. Patients can use their data to seek out providers and services that meet their unique needs as well as better understand their overall health needs, prevent disease, and make more informed decisions about their health care. The department has expressed interest in a similar effort to connect patients to additional data, including data beyond primarily “health care data” to include SDOH-related data.
In response to the comments on the Part I and Part II Advance Notices, the 2020 Medicare Advantage (MA) Final Call Letter was published on April 1, 2019. The Final Call letter includes a number of changes, including the new category of supplemental benefits that may be offered by MA plans – Special Supplemental Benefits for the Chronically Ill (SSBCI). This includes supplemental benefits that are not primarily health related and aims to better enable MA plans to tailor benefit offerings, address gaps in care, and improve health outcomes for the chronically ill population.
On April 5, 2019, CMS issued a final rule that updates the MA or Part C and Medicare Prescription Drug Benefit (Part D) programs through promoting innovative plan designs, improved quality, and choices for patients. Additional flexibilities include MA plans ability to offer “additional telehealth benefits,” increased integration of Medicare and Medicaid benefits and appeals and grievance processes for MA Dual Eligible Special Needs Plans (D-SNPs), and a process to allow Part D plan sponsors to request standards extracts of Medicare Parts A and B claims data regarding enrollees.
On April 2, 2018, CMS expanded the definition of “primarily health related” services. As a result of this reinterpretation, plans now have the flexibility to support patients with SDOH interventions that benefit their health, including transportation support and certain home improvements. In coming plan years, at home remote monitoring & food support may be available. On April 27, 2018, CMS submitted a memo that offers a reinterpretation of the “uniformity requirement” that clarifies non-discrimination for disadvantaged groups.
On October 26, 2018, CMS issued a proposed rule that would eliminate barriers for private MA plans to cover additional telehealth benefits. This includes providing MA plans more flexibility to offer government-funded telehealth benefits, greater ability for MA enrollees to receive telehealth from places like their home, and greater flexibility for plans to offer clinically-appropriate telehealth benefits otherwise not available to Medicare beneficiaries.
On January 30, 2019, CMS released Part II of the 2020 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part D Payment Policies (the Advance Notice), and Draft Call Letter. CMS accepted comments on all proposals in Part I and Part II through March 1, 2019 before publishing the final Rate Announcement and Call Letter on April 1, 2019. Beginning in CY2020, MA plans can offer non-primarily health related supplemental benefits to chronically ill enrollees. The 2020 Call Letter provides guidance about these new special supplemental benefits for the chronically ill, including the definition of a chronic condition and how to submit these benefits in the MA bid (see NASDOH’s comment letter here).
CMS has established a working group on core measure review, where one of the core measures they are considering involves the social determinants of health. The group is headed by the Director of the Division of Quality and Health Outcomes and reports to the Deputy Director of the Center for Medicaid and CHIP Services.
On March 14, 2017, former HHS Secretary Price and CMS Administrator Seema Verma sent a letter to the nation’s governors indicating their intent to work with states to improve their Medicaid programs. They indicated several key areas where they will work to collaborate with states, including improvement of the State Plan Amendment approval process, support innovative approaches to increase employment and community engagement using 1115 waivers, and provide a reasonable process to comply with the Home and Community-Based Services rule.
CMS released a memo on January 11, 2018 that sets forth waiver options for states pursuing SDOH interventions. These could include behavioral health, mental health, opioids focused, or work-related interventions. CMS noted the broad range of social, economic, and behavioral factors that influence or impact an individual’s health and wellness and the growing body of evidence that suggest targeting certain health determinants may improve health outcomes. In particular, CMS noted productive work and community engagement as an area that has the potential to improve health outcomes.
On October 19, 2018, CMS approved North Carolina’s Section 1115 waiver that includes an innovative new pilot program focused on addressing the SDOH for high-risk, high-cost beneficiaries. The waiver allows four regional pilots that assemble a network of health care providers, community-based organizations, and social service agencies that contract with managed care plans to provide services to enrollees. The particular service areas included in the pilot are housing, food, transportation, and interpersonal violence/toxic stress. In addition to the CMCS interest areas mentioned above, CMCS has heard from states who have an interest in emulating some of what North Carolina has done with their waiver, as well as advancing their own concepts. CMCS would like to provide more guidance for those states and their MCOs.
On August 23, 2018, CMMI announced the Integrated for Kids (InCK) model – a model focused on local service delivery and state payment model aimed at reducing expenditures & improving quality of care for children covered by Medicaid or CHIP. The model incorporates prevention, early identification, and treatment of priority health concerns including behavioral health and physical health care utilization. CMS plans to award funding for up to eight cooperative agreements at a maximum of $16 million each in December 2019 to implement the seven-year model beginning January 1, 2020.
On September 8, 2016, CMMI announced the Accountable Health Communities (AHC) model that addresses the gap between critical care and community services through testing whether systematically identifying and addressing health-related social needs of Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. Currently, 30 organizations are participating in the AHC model and the participant performance began in May 2017 and is anticipated to end on April 30, 2022.
On October 23, 2018, CMMI announced the Maternal Opioid Misuse (MOM) model to combat the country’s opioid crisis. Specifically, the model addresses fragmentation in the care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD). The model aims to improve the quality of care and reduce costs for mothers and infants. CMS plans to execute up to twelve cooperative agreements with states, whose Medicaid programs will implement the model with one or more care delivery partners in their communities. A maximum of %64.5 million will be available for state awardees over the five-year model period. The Notice of Funding Opportunity ended on May 6, 2019.
CMS announced Direct Contracting (DC) that aims to improve quality of care and health outcomes, reduce Medicare expenditures through the alignment of financial incentives, and focus on patient choice and care delivery for beneficiaries, including complex, chronic, and seriously ill populations. DC includes three payment model options. CMMI announced an RFI in May 2019 on one DC model – the Geographic Population-Based Payment (PBP) model. This model would allow entities to assume total cost of care (TCOC) risk for Medicare FFS beneficiaries in a defined target region. Comments were due by May 23rd (see NASDOH’s comments here).
In December 2016, the Health Resources and Services Administration and the Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) released “Addressing the Social Determinants of Health: The Role of Health Professions Education” (link). The report details the need to advance education in SDOH for all health care professionals/students and outlines four recommendations for HRSA:
The Health Impact in 5 Years (HI-5) initiative aims to achieve lasting impact on health outcomes within communities through interventions that address the conditions in the places where we live, learn, work, and play. HI-5 focuses on non-clinical, community-wide approaches that have evidence reporting health impacts, results within five years, and cost effectiveness or cost savings.
On March 6-7, 2019, the CDC and the Association of State and Territorial Health Officials (ASTHO) hosted a convening to share knowledge, strengthen relationships, and explore collaborations between participants and community integrators to address health-related social needs.
The Healthy People 2030 framework includes language around “social health,” “eliminating health disparities,” and “social, physical, and economic environments.” One of the overarching goals for 2030 includes: “Create social, physical, and economic environments that promote attaining full potential for health and well-being for all.”
Of particular interest to the agency is how SDOH can support the Department of Health and Human Services’ (HHS) value-based work. The Office of Disease Prevention and Health Promotion partnered with the National Academy of Medicine (NAM) on a workshop “Reducing Health Care Spending Through Interventions that Address Non-Medical Health-Related Social Needs” in Washington D.C. on April 26th. The workshop focused on a wide range of issues related to the social determinants of health including current and potential CMS and private payer reimbursement policies, the role of population-wide policy change, and the latest research on the return on investment (ROI) and value proposition for such work.
The HHS Chief Data Officer (CDO) is interested in better understanding how data and information that exists within various agencies can be successfully shared between and among all agencies to better utilize the data and increase data transparency. They are seeking feedback and recommendations on an HHS report titled, “The State of Data Sharing at the U.S. Department of Health and Human Services” that will be released on September 18, 2019. In addition, the agency is developing Action Steps and plan to convene numerous Federal agencies in the first quarter of 2019 to discuss data sharing (see NASDOH’s March 4th letter to the CDO that highlights several use cases and associated case studies on current activities and efforts here).
The Office of the Chief Technology Officer hosted a roundtable event on October 3rd that focused on how to use data related to social determinants of health to improve health outcomes. The roundtable included discussion on how to catalyze the use of SDOH data at the federal, state, local, and individual levels to improve health outcomes. Participants, in addition to Karen DeSalvo, included the chief data officer (Mona Siddiqui), former U.S. Chief Technology Officer (Aneesh Chopra), President of Center for Open Data Enterprise (Joel Gurin), and HHS Assistant Secretary for Health (Brett Giroir).
The Surgeon General is writing a report on the connection between community health and prosperity, business investment in local community health, investment strategies, the role of a healthy workforce in business success, and contributions of local policy makers toward community development. In an effort to better inform this report, the OSG and Center for Disease Control and Prevention released a Request for Information RFI on September 6, 2018 soliciting view, recommendations, & data on the connection between community health & prosperity (see NASDOH’s November 2018 comment letter here).
The Surgeon General has indicated interest in better understanding the evidence available for specific social determinants of health interventions that may deliver a consistent return on investment (ROI). In response, NASDOH provided the Surgeon General with a letter identifying several organizations and their social determinants of health activities (see letter here).
The Office of the Surgeon General is actively working on its 2020 Surgeon General report expected to be published early next year. Karen DeSalvo and former Utah Governor and HHS Secretary Michael Leavitt are authors on chapter focused on collaborations with public health departments to achieve business and community health goals.
Section 2(d) of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act calls for a study evaluating the effect of individuals’ socioeconomic status (SES) on quality measures and measures of resource use under the Medicare program. The RFI specifically seeks information on how plans and providers serving Medicare beneficiaries with social risk factors, approaches plans and providers have used to address the needs of beneficiaries with social risk factors, evidence regarding the impact of these approaches on quality outcomes and the total cost of care, and ways in which plans and providers disentangle beneficiaries’ social and medical risks. The first report was released in December 2016 and a second report to Congress, expanding on the empirical analyses conducted in the first report, is expected to be complete by October 2019.
In June 2019, ASPE’s Office of Disability, Aging and Long-Term Care Policy released a report, “Housing Options for Recovery For Individuals With Opioid Use Disorder: A Literature Review” that identifies gaps in the literature on housing models to support recovery from opioid use disorder (OUD) in individuals who experience homelessness or housing instability.
On December 12, 2018, the Office of Civil Rights (OCR) announced a request for information (RFI) on how the Health Insurance Portability and Accountability Act (HIPPA) privacy and security rules may impede the transformation to coordinated, value-based health care. Comments were due by February 11, 2019 (see NASDOH’s comment letter here).
The Office of Inspector General (OIG) requested for information from the public on how to address any regulatory provisions that may act as barriers to coordinated care in an attempt to accelerate transformation to a value-based system that included care coordination. The OIG is also reviewing Stark Act Safe Harbors, where appropriate, among social services and health care providers (e.g., providing a patient “something of value”, like transportation vouchers or food bank coupons).
AHRQ asked participants to develop an app that addresses the need for increased use of standardized patient-reported outcomes data in clinical care and research in an effort to bring the voice of the patient into care delivery and wellness processes.
On March 7, 2019, the Agency for Healthcare Research and Quality (AHRQ) announced a “challenge competition” in which participants develop new online tools to present and encourage the use of free, publicly available SDOH data to better understand and foresee communities’ unmet health care needs. These visualization tools must utilize information from at least 3 or more free, publicly available data sources and must be developed and presented so AHRQ can apply them in at least 2 of the following ways:
The challenge includes two phases: In phase 1, participants submit concept abstracts and prototype designs of data visualization methods (due June 7, 2019). In phase 2, semifinalists will develop proofs-of-concept. Phase 1 winners are expected to be announced in July 2019 and begin phase 2.