The

NEW ENGLA ND JOURNAL

of

MEDICINE

Perspective
Accountable Health Communities Addressing Social Needs
through Medicare and Medicaid
Dawn E. Alley, Ph.D., Chisara N. Asomugha, M.D., Patrick H. Conway, M.D., and Darshak M. Sanghavi, M.D.

or decades, experts have described a profound imbalance between public funding of acute medical
care and investments in upstream social and environmental determinants of health.1 By some estimates,
more than 95% of the trillion
dollars spent on health care in
the United States each year funds
direct medical services, even
though 60% of preventable deaths
are rooted in modifiable behaviors
and exposures that occur in the
community.1
Most clinicians are familiar
with the stories behind these
statistics: the child with asthma
whose substandard housing triggers repeated emergency department visits; the patient with repeated visits for severe abdominal
pain caused by her violent home
life; the older adult with diabe-

tes forced to choose between

paying for heat and buying groceries. But in our current system,
patients health-related social
needs frequently remain undetected and unaddressed. Despite
calls for obtaining an expanded
social history at the point of care,2
most health care systems lack the
infrastructure and incentives to
develop comprehensive, systematic screening-and-referral protocols
and relationships with the array
of community service providers
that would be required to address
their patients health-related social needs.

If the rate of preventable hospitalizations among residents of

low-income neighborhoods could
be reduced to the level among
residents of high-income neighborhoods, there would be 500,000
fewer hospitalizations per year.3
As health systems are increasingly
being held accountable for health
outcomes and reducing the cost
of care, they need tools and interventions that address patient and
community factors contributing to
excess utilization. Effective partnerships among medical care,
social services, public health, and
community-based organizations
could improve population health
outcomes, but developing sustainable payment models to support
such partnerships has proved
challenging.4
Some encouraging innovations

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PERS PE C T IV E

Accountable Health Communities

have emerged. Catalyzed in part

by statewide all-payer deliverysystem reform and the growth of
value-based or shared-risk payment models, some purchasers
and providers of medical care
have found innovative ways to
support high-value communityfocused interventions. For example, Hennepin Health, a countybased Medicaid managed-care
organization in Minnesota, has
reduced emergency department
visits by 9% by using housing
and community service specialists who are part of a tightly integrated medical and social service system. Tracking patients
service utilization across clinical
and human-service systems allows
Hennepin to target upstream interventions so that its patient care
can be more effective (as documented in composite quality metrics of asthma, diabetes, and vascular care); the organization has
improved patients access to social
services and reinvested savings
in a broad range of programs.5
Other examples come from the
Health Care Innovation Awards
granted by the Centers for Medicare and Medicaid Services (CMS);
these awards have supported organizations such Chicago-based
CommunityRx, which generates
prescriptions for community services through an interface linking the patients electronic health
record with a community-resource
database, and the Michigan Public Health Institute Pathways to
Better Health Community Hub
model, in which community health
workers perform a structured assessment of clients health and
social service needs and use
standardized pathways to link
beneficiaries to community resources and track outcomes.
These projects have generated
valuable insights regarding ad2

dressing the social determinants

of health, including the importance of establishing cross-sector
partnerships, building data systems that bridge health and community services, and developing
a workforce to deliver interventions to vulnerable populations.
We still lack expertise, however,
in the best ways of scaling these
approaches across myriad settings;
we remain unsure whether broadbased investments improve health
care utilization and costs; and
we need to develop and test a
template that allows a wide variety of communities to undertake
transformation efforts.
To accelerate the development
of a scalable delivery model for
addressing upstream determinants
of health for Medicare and Medicaid beneficiaries, CMS recently
announced a 5-year, $157 million
program to test a model called
Accountable Health Communities
(AHC). Funded under the auspices
of the CMS Innovation Center,
the test will assess whether systematically identifying and addressing health-related social
needs can reduce health care
costs and utilization among
community-dwelling Medicare and
Medicaid beneficiaries.
The foundation of the AHC
model is universal, comprehensive screening for health-related
social needs including but not
limited to housing needs (e.g.,
homelessness, poor housing quality, inability to pay mortgage or
rent), food insecurity, utility needs
(e.g., difficulty paying utility
bills), interpersonal safety (e.g.,
problems of intimate-partner violence, elder abuse, child maltreatment), and transportation difficulties in all Medicare and
Medicaid beneficiaries who obtain health care at participating
clinical sites. Using the data

gathered through this systematic

screening which form a socialneeds diagnostic snapshot of patients and their community
the AHC model aims to address
these underlying health-related
social needs through three tiers
of approaches, with each tier
linked to a payment method (see
table).
The models design recognizes
that communities needs and capacity vary widely, necessitating a
flexible, tracked approach keyed
to various levels of readiness for
change. The tracks which we
have named Awareness, Assistance, and Alignment were
developed on the basis of growing
evidence that linking high-cost
beneficiaries to social services can
improve health outcomes and reduce costs. Prospective participants in the test, termed bridge
organizations, can be community organizations, local health
departments, managed-care organizations, clinical networks, or
other organizations that can demonstrate that they have strong
relationships with clinical and
community partners.
The AHC model is the first
Innovation Center model designed
specifically to test building community capacity to address the
needs of a geographically defined
population of beneficiaries. Our
test will involve robust evaluation
methods (including randomization at the beneficiary level and
matched comparisons at the community level, which are exempt
from human-subjects review under
the Common Rule), is powered to
detect cost savings associated
with each track, and will have a
qualitative-evaluation component.
To be successful, the AHC
model will have to overcome several challenges that have plagued
earlier efforts to build and evalu-

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Startup funds ($250,000)

Payments for screening and referral of Medicare
and Medicaid beneficiaries at participating
clinical delivery sites ($2 per person per
year)

Randomization at the beneficiary level

Payment to bridge organi

zation (applicant)

Evaluation strategy

$1 million

$2.57 million

12

Randomization at the beneficiary level

Startup funds ($750,000)

Same payments for screening and referral as in Track 1
Payments for each high-risk beneficiary who elects to
receive community service navigation services
($86 per person per year)

State Medicaid agency; clinical delivery sites; community service providers

Track 3: Alignment

$4.51 million

20

Matched comparison group and matched comparison communities

Same startup funds, payments for screening,

referral, navigation as in Track 2
Annual lump-sum payments to support backbone
organization ($350,000 per year)

All in Track 2 plus backbone organization focused

on community-wide continuous quality-
improvement approach, including an advisory
board that ensures service provision, adequate
capacity to meet needs, and data sharing to
inform a gap analysis

State Medicaid agency; clinical delivery sites; community service providers; local government;
local payers (MA Plans and Medicaid MCOs)

Will a combination of community service navigation (at the individual beneficiary level) and
partner alignment at the community level reduce total cost of care, ED visits, and admissions?

Screening, referral, community service navigation,

plus partner alignment

* Tracks are mutually exclusive; communities will be selected to participate in a single track. ED denotes emergency department, MA Medicare Advantage, and MCO managed-care
organization.

Total funds per awardee

12

Inventory of local community services

All in Track 1 plus intensive community service navi
Universal screening of all Medicare and
gation (in-depth assessment and follow-up until
Medicaid beneficiaries by medical provider
needs are resolved or unresolvable)
Referral to community services with beneficiary
responsible for completing referral

Intervention components

No. of award sites

State Medicaid agency; clinical delivery sites;

community service providers

Required partners

Will providing community service navigation to assist

beneficiaries with overcoming barriers to access to
services reduce total cost of care, ED visits, and
admissions?

Will increasing awareness of community service availability through information dissemination and referral reduce total cost
of care, ED visits, and admissions?

Track 2: Assistance
Screening, referral, plus community service navigation

Question being tested

Track 1: Awareness

Screening and referral only

Intervention

Variable

Key Features of the Accountable Health Community 5-Year Payment-Model Test.*

PE R S PE C T IV E
Accountable Health Communities

ate clinicalcommunity collaborations. First, major gaps exist in

the evidence base needed to inform the selection of screening
items and the collection of data
for detecting health-related social
needs, as highlighted by a recent
report from the Institute of Medicine.2 AHC sites will be required
to select items from a question
bank prepared by CMS in consultation with experts after extensive
review of existing screening items;
however, ensuring that these
questions are reliable for various
delivery modes and patient populations will be a key challenge.
Maintaining a motivated and
skilled stable of community navigators will also be challenging.
Second, community needs and
the quality of resources vary significantly, resulting in a challenging degree of complexity for
a national test. Thats why the
AHC project includes three incremental levels of integration of
care delivery, which can be deployed in multiple settings. The
model permits flexibility in each
track and incorporates extensive
local support and technical assistance to help sites integrate interventions into their workflows.
For example, in addition to the
standard list of social needs that
all participants will try to address, bridge organizations can,
on the basis of community needs
assessment, select additional
needs to target. Sites can also
choose how an intervention is
delivered by mobile device, in
person at clinical sites, or
through home visits depending on the setting (for instance,
whether it is rural or urban). In
the advanced track (Alignment),
CMS will fund a backbone organization that will facilitate data
collection and sharing among all
partners and try to enhance ser-

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PERS PE C T IV E

Accountable Health Communities

vice capacity, testing the scalability and effectiveness of this backbone structure.
The AHC model reflects a
growing emphasis on population
health in CMS payment policy,
which aims to support a transition from a health care delivery
system to a true health system.
The AHC test will improve our
understanding of whether savings
can materialize when upstream
factors are addressed through
collaboration among stakehold-

ers who are accountable for the

health and health care of their
community.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Centers for Medicare and Medicaid
Services, Baltimore.
This article was published on January 5,
2016, at NEJM.org.
1. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff
(Millwood) 2002;21:78-93.

2. Adler NE, Stead WW. Patients in context

EHR capture of social and behavioral determinants of health. N Engl J Med 2015;372:
698-701.
3. Potentially preventable hospitalizations
United States, 20012009. MMWR Surveill Summ 2013;62:Suppl 3:139-43.
4. Eggleston EM, Finkelstein JA. Finding the
role of health care in population health.
JAMA 2014;311:797-8.
5. Sandberg SF, Erikson C, Owen R, et al.
Hennepin Health: a safety-net accountable
care organization for the expanded Medicaid
population. Health Aff (Millwood) 2014;33:
1975-84.
DOI: 10.1056/NEJMp1512532
Copyright 2016 Massachusetts Medical Society.

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The New England Journal of Medicine

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Copyright 2016 Massachusetts Medical Society. All rights reserved.