Hospitals need more social workers and a way to afford them

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.”

Despite the difficulties in getting reimbursement for their services, social workers seem to be well-qualified to help guide hospitals as they address health matters that fall within the purview of public health and social services. “Social workers fit very well in the work that needs to be done to address social determinants of health,” Bathija said.

Most health systems use social workers to identify and fulfill a patient’s need for services by screening them and connecting them with food, housing, transportation, counseling or other services provided within the healthcare system or through community partners such as homeless shelters or food banks.

Some health systems deploy social workers as part of interdisciplinary care-delivery teams that coordinate care and assist with discharge planning. Social workers increasingly are part of teams with physicians, physical therapists, pharmacies and skilled-nursing facilities to ensure that patients will be able to comply with an appropriate course of care after discharge. That can help reduce readmissions and improve patient satisfaction.

The varied types of services that social workers provide within health systems only makes the vexing problem of how to pay for their efforts worse.

“At the surface level, there appears to be some inconsistency in paying for things that aren’t really healthcare,” McDonald said.

Some of the problems are mainly administrative and should become easier to address as social workers’ roles in the health system grow over time. For example, there aren’t medical codes—known as Current Procedural Terminology codes—for the services that social workers provide, according to Angelo McClain, CEO of the National Association of Social Workers.

But other issues could prove more challenging to resolve.

The CMS recently approved increased payments to physicians for evaluation and management visits after complaints from doctors that they weren’t being paid enough for the amount of time they spend with patients.

That means other providers will see their reimbursements cut to pay for the bump that physicians will receive beginning in 2021. Meanwhile, social workers face the prospect of a 7% cut in payments for behavioral health services under the proposed 2021 physician fee schedule. Federal law requires that the payments remain budget-neutral to keep health spending in check. An increase for some providers means a decrease for others, making it a zero-sum game.

Pitting care providers against one another might be helpful when it comes to limiting reimbursements under original, fee-for-service Medicare, but experts say it may not the best way to coordinate patient care, address social determinants of health or drive down total healthcare spending long term.

“Do physicians really need to be coordinating care? No,” McDonald said. “Let’s move down the spectrum to lower-cost care providers such as social workers.”

Unlike many healthcare providers, social workers have a broad scope of practice because they focus on caring for people and their families within their environment. They tackle everything from issues of food and income insecurity to drug use and domestic violence. They also serve as behavioral health providers, care coordinators and community referral specialists. It’s a holistic approach to providing care that allows them to work effectively within integrated care teams.

“There are so many things that social workers can do,” said Lisa de Saxe Zerden, senior associate dean at the University of North Carolina at Chapel Hill School of Social Work.

But that broad scope of practice, while beneficial to patients, creates professional barriers for social workers in the healthcare field because hospitals and insurers don’t know how to account for the services that social workers provide.

Licensing has proven to be a significant hurdle for providers and payers alike. There are no national standards for licensing social workers to work within the healthcare system and qualifications vary considerably across states.

“There aren’t clear rules about how to credential them, which creates challenges for payers in terms of deciding who is appropriate to provide services to their members,” McDonald said.

Standards vary so much that it’s difficult for researchers to get an accurate count of how many credentialed social workers exist in the U.S., which can make workforce planning difficult because there’s uncertainty about availability.

There’s also a bottleneck in the pipeline of social workers who can treat behavioral health issues. New social work graduates who trained in integrated care settings are having trouble getting hired because they’re unlicensed, de Saxe Zerden said.

That’s despite the availability of funding for professional substance abuse and behavioral health training from the Health Resources & Services Administration through its Behavioral Health Workforce Education and Training grant program.

“Most health systems want their social workers to be licensed, but it takes two-plus years for social workers to be licensed,” de Saxe Zerden said. “We don’t really know where they go during those two interim years.”

Social workers might work on grant-funded projects, policy issues or under the direction of a licensed clinical social worker during the period between graduation and licensing, but the data is murky.

Unlike doctors and other health professionals who complete a residency or similar program, there’s nothing available for social workers who want to work in integrated care settings. That makes it tough for social workers to work in the healthcare system early in their careers.

“You don’t have to do clinical work,” said Christine Rine, associate professor and head of the master’s degree program in department of social work at Edinboro (Pa.) University. But “once people have a clinical license, things are more set in stone in terms of reimbursement.”

It’s a doughnut hole in the professional development of social workers who work in the healthcare delivery system.

So some hospitals are using community health workers to provide care, even though they might not be the most appropriate provider, because it’s easier to get reimbursed for their services.

“When push comes to shove, they’re using community health workers instead of social workers because, in their state, there’s payment for community health workers and there’s not payment for social workers,” Bathija said. “It’s different in each state based on their Medicaid programs.”

Value-based payment and other models that tie reimbursement to healthcare quality could drive new demand for social workers to address the social determinants of health as part of integrated care-delivery teams.

But it’s still hard for social workers to get paid for the services they provide because fee-for-service payments still dominate the healthcare system. It’s unlikely the industry will be able to get enough of the social workers it needs until it starts paying for the work they do.

“If we have a workforce issue, let’s reimburse and value the services so that we can develop a larger workforce to meet this need,” McDonald said. “I think it’s a great theory and I hope that it pans out, but it’s a complicated, long-term process.”