April showers bring social determinants of health flowers

The showers of April have brought a burst of blooms in the Social Determinants of Health (SDoH) reimbursement garden. First, the Centers of Medicare and Medicaid Services (CMS) released its 2020 rate sheet. As expected by the industry, Medicare Advantage and Part D plan supplemental benefits are set to expand in several areas. The emphasis on care moving outside of hospitals translates to a necessary increase in reimbursement for non-clinical resources and programs that help to minimize readmissions, as well as enhance the wellness of populations.

In 2016 CMS amended the Medicaid Managed care rule so Medicaid MCOs could support patients with nonmedical expenses. There has been talk since by CMS about the need to further expand coverage of non-clinical services that directly impact population health (e.g. air filter systems, fans). Yet, it was insurance companies, especially the Managed Medicaid and Medicare Advantage providers that stepped up first to bridge the needs gap. The majority provide robust funding for gaps in transportation, nutrition, GED prep classes and tests, employment, linkage to fitness programs, plus.

Fast forward to 2020 and CMS will begin to pay for services that promote healthy home environments, expanding coverage to two main SDoH: food insecurity and access to care (AKA: transportation). Traditionally where CMS goes the other payers follow, but in the scope of the SDoH it presents the reverse is true. The reimbursement expansion by CMS is set to include the following:

  • Meal delivery
  • Transportation to the grocery store
  • Nutrition services, and
  • Coverage for non-emergency medical transportation
  • Expansion of diabetes education in outpatient programs and community health facilities, with
  • Increase in the number of education hours, from 10 to 16 hours, and number of follow-up sessions: from 2 to 6 hours.

The opioid crisis will also receive greater fiscal emphasis, with supplemental benefits for patients with opioid use disorders. In addition, cost-sharing reductions for those persons who live with chronic pain will also be added. Medicare Part D plans will add at least one overdose reversal drug to the low cost-sharing tier. It is hoped this action will improve access to medications for those persons who need them.

Telehealth reimbursement will see expansion for remote patient monitoring under certain circumstances. Social cohesion and isolation are major SDoH, particularly for children and adults who live with disabilities, and adults receiving services under Long Term Services and Support programming. Telehealth services help directly address this determinant through an array of virtual programs and care processes.

The American Medical Association and UnitedHealth Care
The other hearty April blossom came with the American Medical Association announcing their alignment with United Healthcare to advance 23 new ICD-10 codes that address social barriers to care (AKA: the SDoH). Keep in mind that UnitedHealthcare already joined with NCQA and the National Association of Community Health Centers to advocate with CMS for code expansion of the most popular SDoH of food insecurity and access to care in the form of transportation. The expanded ICD-10 code recommendations encompass six key areas. These include the following:

  • Access to nutritious food
  • Appropriate housing
  • Transportation
  • Expanded payment for medications
  • Utilities, and
  • Caregiver needs.

The pressure is on for payers to empower new means of reimbursement for the SDoH, particularly with compelling recent evidence how the determinants impact 80 percent of health outcomes, and cause over 50 percent of readmissions. Now, expansion of the ICD-10 codes is a big plus for all, but only a small part of how to boost revenue.  If the organization’s processes aren’t in place to make the best use of the codes, then they are for naught. It is just over a year that the American Hospital Association (AHA) approved non-clinical documentation from the interprofessional team to validate the use of the ICD10 Z codes; the psychosocial and socioeconomic stressor that impact health and behavioral healthcare outcomes and speak to the SDoH.

Providers must still hone their documentation skill and the efforts to assure they are garnering their share of appropriate reimbursement. Collaborative coalitions and communication are a must for all professionals involved in the documentation and coding effort. It will be quite interesting to see just how many organizations have been able to successfully use the Z codes, plus how much money they have captured. In the meantime, if CMS adopts the expanded ICD-10 codes, they may begin as early as 2020. My gut says it is a pretty good guess that we will see one mega roster of ICD-10 codes to be used for the SDoH come October.

Stay tuned for further updates on this exciting topic!


Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP

Ellen Fink-Samnick is an award-winning healthcare industry expert. She is the esteemed author of books, articles, white papers, and knowledge products. A subject matter expert on the Social Determinants of Health, her latest books, The Essential Guide to Interprofessional Ethics for Healthcare Case Management and Social Determinants of Health: Case Management’s Next Frontier (with foreword by Dr. Ronald Hirsch), are published through HCPro. She is a panelist on Monitor Mondays, frequent contributor to Talk Ten Tuesdays, and member of the RACmonitor Editorial Board.

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