CMS Policy Update
In a series of blog posts, outgoing Center for Medicaid and Medicare Services (CMS) Administrator Seema Verma outlined her perspective on the accomplishments of her agency over the last four years. One of the posts provided an overview of changes to address social determinants of health, such as access to nutritious food.
Some highlights from this post include the following:
Support for value-based payment models - this form of payment, which is contrasted with standard “fee for service” payment, supports food access by providing more flexibility in how health care practices are reimbursed and by aligning incentives to invest further “upstream” in preventive measures such as food access. See our Sustainable Funding page for more information.
Changes to E&M coding and payment - think of these as the codes that correspond to how much providers get paid for a basic office visit. The American Medical Association (AMA) manages the definitions attached to these codes, including what corresponds to higher payment levels. CMS sets reimbursement. This year those codes changed to make the time spent with patients relatively more important in coding, to count total time not only face-to-face time (so, for example, time on referrals and notes), and to reflect SDOH Z codes. This sets the stage for more, paid, time addressing contributing factors to health - explained in more detail in this straightforward ICD10 blog post.
Chronic Care Management - one shortcoming of our medical payment system is that it’s built around the idea of a patient coming into a doctor’s office for a full visit. But we know that many conditions, diabetes for example, benefit instead from frequent brief check-ins, like phone calls. These allow a health care worker to find out about things like how a diet is going, is there enough food in the house, are there any questions or concerns. Value-based payment models permit this kind of flexibility but those take a long time to set up. CMS now offers a Chronic Care Management program that is built on the current fee-for-service system, but accommodates frequent check-in type care.
Medicare Advantage flexibilities - Medicare Advantage plans offer much more flexibility than traditional Medicare. While these plans have had limited use in Vermont previously, in 2021 they are expanding with a new option from BlueCross BlueShield of Vermont. Examples of flexibilities include delivery of medically tailored meals and transportation to non-medical appointments, such as for grocery shopping.
Medicaid options - CMS can also allow Medicaid programs to enter into more flexible contracts. While we think of Medicaid as a state-run program, the money for benefits is matched by the federal government and they have a lot of say in how the programs get structured. Verma’s blog suggests several ways that states could get flexibility to invest more in addressing social determinants of health, the one most relevant to Vermont is likely the 1115 waiver provided to North Carolina in 2018. Here is a short write up of what that agreement allows.
SDOH data collection - collecting data nationwide is complicated, the Policy in Plainer English episodes on food insecurity screening gave a sense of how complicated it can be for just one issue in just one state. Collecting usable information on contributing factors to health requires addressing standardization of definitions, screening procedures, how data gets entered into electronic health records, and how it’s accessed. And that’s before you get into how to then get that data into practical use for goals like referring across agencies and providing appropriate follow up. While CMS tackles these macro data questions, they also are gathering data on the impact of policy changes they’ve made to support health practices in ‘whole person’ treatment - this data is critical to moving initiatives from pilots and special programs to standard practice.