Universal social determinants of health screening cuts $200M

AHC Model improves outcomes, cuts costs

Perhaps most importantly, both tracks of the AHC Model were effective at screening for and detecting health-related social needs (HRSNs).

Program participants screened 1.1 million Medicaid and fee-for-service (FFS) Medicare beneficiaries for five key HRSNs, including housing instability, food insecurity, transportation problems, difficulties paying for utilities and interpersonal violence.

All said, 37% of beneficiaries across payer types screened positive for at least one HRSN. These patients had high healthcare needs, with 18% of beneficiaries having at least two ED visits within the previous 12 months. Most were also eligible for care navigation, or assistance in coordinating their healthcare and social services.

In other words, the AHC Model included many patient participants who could benefit from the program's offerings, CMMI indicated.

Overall, the program was successful across both tracks, the agency added.

For the Assistance Track, CMMI experts found improvements in healthcare expenditures and utilization, including the following metrics:

• 3% reduction in total expenditures for Medicaid enrollees and a 4% reduction among FFS Medicare enrollees.
• 3% reduction in all-cause inpatient admissions and a 7% reduction in unplanned readmissions for Medicaid beneficiaries. For Medicare, there was an 8% reduction in ambulatory care-sensitive condition admissions and a 7% reduction in unplanned readmissions.
• 4% reduction in ED visits and 5% reduction in avoidable ED visits for FFS Medicare beneficiaries.
• 1% reduction in specialist visits among Medicaid beneficiaries. For FFS Medicare beneficiaries, there was a 4% reduction in primary care visits and 3% reduction in specialist visits.

The Alignment Track also saw significant success, including the following metrics:

• Medicaid beneficiaries had a 7% reduction in total expenditures.
• Medicaid beneficiaries had a 3% reduction in ED visits and 3% reduction in avoidable ED visits.
• Medicaid beneficiaries had a 5% reduction in PCP visits. For FFS Medicare beneficiaries, that figure was 4%.

Reductions in unnecessary healthcare utilization and the cost savings they yield underscore the AHC Model's overall efficacy, CMMI suggested. The crux of this success is likely the healthcare navigation that the model offered.

Care navigators drive AHC Model success

According to CMMI, the AHC Model was effective likely because it provided patients with a care navigator with whom they built strong trust.

Strong trust in an individual's navigator might have translated into improved trust in the healthcare industry overall, yielding stronger patient engagement. Moreover, the patient-navigator relationship might have helped keep patients on track with their care management activities.

Still, CMMI urged policymakers to understand the program's nuances.

For example, the model was more effective among individuals with at least one chronic illness, likely because this population had higher baseline healthcare utilization. The researchers also observed that even partially addressing HRSNs helped improve health outcomes.

Other factors influenced outcomes, too. For example, navigation services were more effective when they were provided alongside other alternative payment models and when they were provided to beneficiaries who were dually eligible for Medicare and Medicaid.

Finally, the researchers observed that some HRSNs had a bigger impact than others. Specifically, navigation services were more impactful for folks with transportation needs or with multiple HRSNs.

These findings are important because they confirm that SDOH work is feasible. According to CMMI, the AHC Model demonstrated that organizations can universally screen for SDOH without disrupting provider workflows.

Still, there are challenges associated with implementing such a model. For example, care navigators struggled to know which community resources had the capacity to accept new clients. To that end, many community organizations lacked the resources necessary to meet increased demand.

Those challenges should not dampen enthusiasm for widespread SDOH work, CMMI suggested. Rather, they should prompt a second look at community resourcing on a policy level.

"A nuanced approach that integrates social care with medical care enhances the patient experience, ensures patients receive tailored assistance and can empower them to navigate complex health systems," the report concluded.

"Understanding the intensity of navigation needed, investing in community service capacity and aligning initiatives with broader care transformation efforts will achieve the greatest impact."

Sara Heath has reported news related to patient engagement and health equity since 2015.