Addressing Social Needs in Primary Care Not Federally Funded

The costs of providing evidence-based interventions in primary care to address social needs far exceed current federal funding streams, say the authors of a new analysis.

A microsimulation analysis by Sanjay Basu, MD, PhD, with Clinical Product Development, Waymark Care, San Francisco, and colleagues found that, as primary care practices are being asked to screen for social needs, the cost of providing evidence-based interventions for these needs averaged $60 per member/person per month (PMPM) (95% confidence interval, $55-$65).

However, less than half ($27) of the $60 cost had existing federal financing in place to pay for it. Of the $60, $5 was for screening and referral.

The study results were published in JAMA Internal Medicine.

The researchers looked at key social needs areas and found major gaps between what interventions cost and what's covered by federal payers. They demonstrate the gaps in four key areas. Many people in the analysis have more than one need:

Food insecurity: Cost was $23 PMPM and the proportion borne by existing federal payers was 61.6%.
Housing insecurity: Cost was $3 PMPM; proportion borne by federal payers was 45.6%.
Transportation insecurity: Cost was $0.1 PMPM; proportion borne by federal payers was 27.8%.
Community-based care coordination: Cost was $0.6 PMPM; proportion borne by federal payers is 6.4%.

Gaps varied by type of center

Primary care practices were grouped into federally qualified health centers; non-FQHC urban practices in high-poverty areas; non-FQHC rural practices in high-poverty areas; and practices in lower-poverty areas. Gaps varied among the groups.

While disproportionate funding was available to populations seen at FQHCs, populations seen at non-FQHC practices in high-poverty areas had larger funding gaps.

The study population consisted of 19,225 patients seen in primary care practices; data on social needs were pulled from the National Center for Health Statistics from 2015 to 2018.

Dr. Basu said in an interview with the journal's deputy editor, Mitchell Katz, MD, that new sustainable revenue streams need to be identified to close the gap. Primary care physicians should not be charged with tasks such as researching the best housing programs and food benefits.

"I can't imagine fitting this into my primary care appointments," he said.

Is primary care the best setting for addressing these needs?

In an accompanying comment, Jenifer Clapp, MPA, with the Office of Ambulatory Care and Population Health, NYC Health + Hospitals, New York, and colleagues wrote that the study raises the question of whether the health care setting is the right place for addressing social needs. Some aspects have to be addressed in health care, such as asking about the home environment for a patient with environmentally triggered asthma.

"But how involved should health care professionals be in identifying needs unrelated to illness and solving those needs?" Ms. Clapp and colleagues asked.

They wrote that the health care sector in the United States must address these needs because in the United States, unlike in many European countries, "there is an insufficient social service sector to address the basic human needs of children and working-age adults."

Eligible but not enrolled

Importantly, both the study authors and editorialists pointed out, in many cases, intervening doesn't mean paying for the social services, but helping patients enroll in the services for which they already qualify.

The study authors wrote that among people who had food and housing needs, most met the criteria for federally funded programs, but had low enrollment for reasons including inadequate program capacity.

For example, 78% of people with housing needs were eligible for federal programs but only 24% were enrolled, and 95.6% of people with food needs were eligible for programs but only 70.2% were enrolled in programs like the Supplemental Nutrition and Assistance Program and Women, Infants and Children.

Commentary coauthor Nichola Davis, MD, also with NYC Health + Hospitals, said one thing they've done at NYC Health + Hospitals is partner with community-based organizations that provide food navigators so when patients screen positive for food insecurity they can then be seen by a food navigator to pinpoint appropriate programs.

The referral for those who indicate food insecurity is automatically generated by the electronic health system and appears on the after-visit summary.

"At the bare minimum, the patient would leave with a list of resources," Dr. Davis said.

One place primary care providers can make a difference

Dr. Katz said that the $60 cost per person is much lower than that for a service such as an MRI.

"We should be able to achieve that," he said.

Will Bleser, PhD, MSPH, assistant research director of health care transformation for social needs and health equity at the Duke-Margolis Center for Health Policy, Washington, said it's exciting to see the per-person cost for social needs quantified.

He pointed to existing revenue options that have been underutilized.

Through Medicare, he noted, if you are part of a Medicare Advantage plan, there is a program implemented in 2020 called Special Supplemental Benefits for the Chronically Ill. "That authorizes Medicare Advantage plans to offer non–primarily health-related services through Medicare Advantage to individuals who meet certain chronic illness conditions."

Non–primarily health-related services may include meals, transportation, and pest control, for example, the Centers for Medicare & Medicaid Services notes.

Also, within the shared-savings program of traditional Medicare, if an accountable care organization is providing quality care under the cost target and is reaping the savings, "you could use those bonuses to do things that you couldn't do under the normal Medicare fee schedule like address social needs," Dr. Bleser said.

Medicaid, he said, offers the most opportunities to address social needs through the health system. One policy mechanism within Medicaid is the Section 1115 Waiver, where states can propose to provide new services as long as they comply with the core rules of Medicaid and meet certain qualifications.

Avoiding checking boxes with no benefit to patients

Ms. Clapp and colleagues noted that whether health care professionals agree that social needs can or should be addressed in primary care, CMS will mandate social needs screening and reporting for all hospitalized adults starting in 2024. Additionally, the Joint Commission will require health care systems to gauge social needs and report on resources.

"We need to ensure that these mandates do not become administrative checkboxes that frustrate clinical staff and ratchet up health care costs with no benefit to patients," they wrote.

Dr. Basu reported receiving personal fees from the University of California, Healthright360, Waymark and Collective Health outside the submitted work; he has a patent issued for a multimodel member outreach system; and a patent pending for operationalizing predicted changes in risk based on interventions. A coauthor reported grants from the North Carolina Department of Health and Human Services, Blue Cross Blue Shield of North Carolina, and personal fees from several nonprofit organizations outside the submitted work. Another coauthor reported personal fees from ZealCare outside the submitted work.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.