Monday, January 4, 2016

Medicare, Medicaid, and Social Needs
The foundation of the Accountable Health Communities Model is universal, comprehensive screening for health-related social needs , food insecurity, utility needs, interpersonal safety, and transportation  difficulties – in all Medicare and Medicaid beneficiaries.

Dawn E. Alley, Phd, et al, from the Centers of Medicare and Medicaid Services, “Accountable Health Communitites – Addressing Social Needs through Medicare and Medicaid,” NEJM,  January 7, 2015

Part of the purpose of this blog is to slice through federal jargon and reduce it to simple language.
An example of this jargon appears in the opening paragraph in the NEJM article cited above:
For decades experts have described a profound imbalance between public funding of acute medical care and investments in upstream social and environmental determinants of health.  By some estimates, more than 95% of the trillion dollars spent on health care in the United States funds direct medical services, even though 60% of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community.
Later near the end of the article,  the authors explain that upstream social and environment determinants of health  and modifiable behaviors and exposures include  homelessness, poor housing quality, inability to pay mortgages or rents, lack of adequate food,   domestic violence, elder abuse, child mistreatment, and transportation difficulties.
To address these social needs, CMS has announced a 5-year $157 million program to test a model called Accountable Health Communities (AHC)to systematically identify and address health-related social needs to reduce health costs and utilization among Medicare and Medicaid’s  125 million recipients. 

Of course,  as with all federal programs, the AHC program is to be “universal and comprehensive” and will involve “robust evaluation, ” as well as thorough “collaboration among stakeholders  who are accountable for the health and health care of their community." And AHC will, no doubt, be “affordable,” just as the  Patient Protection and Affordable Care Act promised to be.
Nowhere in the article is mentioned the existence of a private organization known as Health Leads, which now functions in a half dozen major cities across the U.S.    Health Leads does much of what AHC promises to do.   It fills the “social needs” vacuum by  setting up “help” desks,  funded by college-aged volunteers, in medical clinics and hospitals  to connect needy patients with such social services such as  social workers,  home care nurses,  help with finding jobs, housing  authorities, and arranging health care transportation. 

Physicians can write “prescriptions” to give needy patients access to these services.   Physicians are Health Leads sites welcome these services,  and the Physicians Foundation thinks so much of Health Leads that it has rewarded the company with several million dollar grants.

The CMS Accountable Health Communities  universal comprehensive program  and Health Lead's more modest initiative approach illustrates two fundamental approaches to health reform.

One,  the universal, comprehensive, utopian approach, which says:  You must serve all of the people, all of the time,  for all of their needs,  from the top-down for all of the people serviced by government.

Two,  the incremental  pragmatic, less-than-ideal  approach, which says:  You can serve many of the people,  much of the time, for the most pressing of their needs, from the bottom-up, when the occasion demands.



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