While social workers have an essential role in addressing the social determinants of health, hospitals and insurers are having trouble agreeing on how to pay for the work they do.
There’s also confusion about scope of practice and who’s considered a social worker, which feeds into the difficulties in how to reimburse hospitals for their services. And there is competition for reimbursement from other providers too.
The result is that these caregivers’ needed skills may go unused for nonclinical reasons.
“Across the board, when I speak to hospitals, it’s still a challenge in terms of actually getting the services of social workers paid,” said Priya Bathija, vice president of the Value Initiative, an effort of the American Hospital Association.
Nonmedical determinants of health account for an estimated 80% to 90% of a population’s modifiable health, according to a paper published by the National Academy of Medicine. That includes things like where people live, how wealthy they are, their level of education and what their home and family lives are like.
Historically, the healthcare system hasn’t dealt with those issues head-on because there’s never been a good way for providers to get paid for doing it, even though social factors are critical to health outcomes. “Social determinants are everything,” said Kate McDonald, a partner at McDermott Will & Emery.
Yet there’s been increasing interest in how to address them within the healthcare system because they have such an outsized impact on people’s health. That’s been especially true as new value-based payment approaches like alternative payment models and accountable care organizations grow in usage. The new payment models increasingly tie payment to health outcomes rather than rewarding providers for delivering medical procedures and services alone.
“There’s definitely interest in addressing the social determinants of health by changing the paradigm of what is reimbursable through a health insurance plan,” McDonald said.
In recent years, states and the federal government have pushed several initiatives aimed at addressing the social determinants of health.
One change allows Medicaid managed-care organizations to provide enrollees with supplemental benefits such as food aid or transitional housing. The changes also let health plans provide services intended to address the social determinants of health in place of traditional medical services. In 2017, the CMS issued regulations requiring managed-care organizations to coordinate the benefits they provide to enrollees with the aid their beneficiaries get from other sources, such as social services.
And recent changes to the fast-growing Medicare Advantage program allow plans to provide distinct benefits to enrollees based on their health status, supplemental benefits for chronically ill patients that specifically address social determinants of health, and new services such as meal delivery, transportation and other social supports.
“There are so many opportunities for social workers to work with individuals to identify which of these resources might be available to them,” McDonald said. “This provides an avenue for Advantage plans to reimburse for those services and count it as a supplemental medical benefit … instead of an administrative cost.”