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CMS Seeks Providers for Socioeconomic Population Health Program

CMS is offering millions in grant money to providers who can address socioeconomic insecurities within their population health management programs.

By Jennifer Bresnick

- CMS is continuing to promote the importance of addressing the socioeconomic determinates of health in population health management programs by revamping the participation criteria for its Accountable Health Communities (AHC) Model.

Population health management and socioeconomic patient needs

The program offers three federally funded tracks for community-based health organizations, primary care providers, health systems, and other stakeholders to build their population health competencies with a particular emphasis on non-clinical issues that impact patient care, said CMS Principle Deputy Administrator and Chief Medical Officer Patrick Conway, MD.

“This is the first Center for Medicare & Medicaid Innovation model to focus on the health-related social needs of Medicare and Medicaid beneficiaries,” Conway said in a CMS blog post. “Many of these social issues, such as housing instability, hunger, and interpersonal violence, affect individuals’ health, yet they are rarely, if ever, detected or addressed during typical health care-related visits.”

“The AHC Model is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.”

The AHC initiative was first announced in January of 2016 to address the gaps between traditional clinical care and the external issues that may negatively impact access to services, medication adherence, patient education and health literacy, access to communication opportunities, and other crucial health-related issues.

“We recognize that keeping people healthy is about more than what happens inside a doctor’s office, and that’s why, for the first time, we are testing whether screening patients for health-related social needs and connecting them to local community resources like housing and transportation to the doctor will ultimately improve their health and reduce the cost to taxpayers,” said HHS Secretary Sylvia M. Burwell during the initial announcement.

“The Accountable Health Communities model is yet another step towards building a health care system that results in healthier people and stronger communities and spends our health care dollars more wisely.”

The three tiers of the model address different stages of population health management, CMS explained on its website.  Track 1 focuses on building awareness of community services among Medicare and Medicaid beneficiaries.  Track 2 providers will actively provide navigation services to patients with community-based needs, and Track 3 organizations will foster strong partnerships with community service organizations to ensure that the care continuum as a whole is responsive and well-aligned.

CMS is planning to choose 44 applicants who may receive up to $1.7 million for participation in the lowest level of the program and $4.5 million for enrolling in Track 3.  The total funding amount set aside for the AHC program is $175 million, CMS said in January.

While the potential monetary rewards have brought in some applications for the program, CMS is hoping that lowering the bar to attract additional interest from a broader pool of potential participants may bring more success to the initiative.

“The original Funding Opportunity Announcement requested applications for three different scalable tracks featuring interventions of varying intensity that would address health-related social needs for beneficiaries,” Conway wrote. “After receiving significant interest, inquiries and stakeholder feedback, CMS has decided to make modifications to the Track 1 application requirements and is releasing a new Funding Opportunity Announcement (FOA) specific to Track 1 of the AHC Model.”

The original FOA required applicants to screen 75,000 beneficiaries per year for potential socioeconomic issues and follow-up opportunities, but the revised guidelines will reduce that number to 53,000 patients.

CMS will also increase the maximum funding amount per Track 1 award recipient from $1 million to $1.17 million over 5 years to better cover the costs of implementing population health management screening and coordination tools and strategies.  The funding cannot be used to directly pay for community services such as housing and transportation, CMS notes, but must be used to support interventions aimed at connecting beneficiaries with existing community-based offerings.

“The AHC Model complements CMS’ growing focus on population health by providing the necessary tools and support for a successful transition to a holistic health system,” Conway concluded. “The AHC Model will also enhance CMS’ understanding of the impact of interventions to address social needs on health care costs. We look forward to the applications to this FOA.”

Interested parties can learn more about the Accountable Health Communities program on the CMS website, and may submit applications via the Grants.gov portal.


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