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11/8/20  5:11 pm
Commenter: Benjamin Barber, VCU Health System

VCU Health System Comment In Response to High Needs Support Benefit Delivery System Design

November 12, 2020

The Honorable Karen Kimsey, Director

Department of Medical Assistance Services

Department of Health and Human Resources


RE: DMAS Seeking Public Comments on High Needs Support Benefit Delivery System Design

The Virginia Commonwealth University Health System Authority (VCU Health System) appreciates the opportunity to comment on the Department of Medical Assistance Service's (DMAS) High Needs Support Benefit Delivery System Design General Notice.


Based in Richmond, VCU Health System is the academic medical center for Virginia Commonwealth University (VCU), one of the Commonwealth of Virginia’s premier public research universities. VCU Health System’s mission is to preserve and restore health for all people in Virginia, and it is committed to leading the nation in quality, affordability, and impact as a trusted and preferred academic health system.


VCU Health System is the primary provider of services to Medicaid beneficiaries and uninsured individuals in central Virginia. It is comprised of VCU Medical Center (the region’s safety net and No. 1-ranked hospital), the Children’s Hospital of Richmond at VCU, Community Memorial Hospital in South Hill, Virginia, two nursing homes, and two physician practice plans.


VCU Health System commends DMAS’s work to implement the High Needs Supports (HSN) benefit program for high need Medicaid enrollees and for acknowledging the need to address enrollees' social determinants of health. The HSN benefit program will have an especially significant impact during economic downturns like the current recession. It will also improve enrollees’ health outcomes and promote equitable access to needed services.


Addressing the Social Determinants of Health


A growing body of research shows that the social determinants of health - the conditions in which people are born, grow, work and age - are key drivers of health outcomes (World Health Organization, 2011). There is also growing consensus that clinical care accounts for only 20 percent of the modifiable contributors (or factors) to health outcomes

for a population (National Academy of Medicine, 2017). Health behaviors, social and economic factors, and the physical environment account for the other 80 percent (Hood et al., 2016). Food insecurity, lack of stable housing, and inadequate access to transportation are just a few social determinants that influence health outcomes.


While medicine has made extraordinary advances in the past century, less attention has been paid to the social determinants of health. Although the United States spends far more than any other country on health care as a share of Gross Domestic Product (GDP), it spends only a modest amount on social needs. The result is discouraging – Americans, even those with comprehensive health insurance, suffer from alarmingly high rates of health-related social needs. According to recent data published by the Centers for Medicare and Medicaid Services, 67 percent of Medicare and Medicaid beneficiaries with high Emergency Department utilization struggle with food insecurity; 47 percent struggle to maintain stable housing; and 41 percent do not have adequate access to transportation (CMS, 2020).


Addressing the Social Determinants of Health at VCU Health System


As the primary provider of services to Medicaid beneficiaries in central Virginia, VCU Health System experiences in its daily work the importance of social determinants of health and is a leader in addressing them. VCU Health System participates in CMS's Accountable Health Communities model that tests "whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services" will improve health outcomes and reduce costs (CMS, 2017). VCU Health System also partners with many community organizations to help patients resolve their health-related social needs.


These efforts have improved health outcomes. As part of VCU Health System's health equity initiative, a pilot program was launched in one of VCU Medical Center's General Medicine inpatient units to screen inpatients for health-related social needs, provide heart-healthy food boxes upon discharge, and connect them to community resources. During the first year of this pilot, readmission rates among the intervention population dropped compared to the readmission rate for the unit as a whole. VCU Health System's partnership with Virginia Supportive Housing's New Clay House provides supportive housing and care management services for 10 VCU Health System patients with complex care needs - including five patients with sickle cell disease. Thus far, the partnership has yielded a 30 percent decrease in the cost of care for these patients at VCU Health System and a 75 percent decrease in 30-day inpatient returns over six months.


The Importance of a High Needs Support Benefit


Unfortunately, these partnerships are difficult to scale and sustain during economic downturns. Many organizations that address health-related social needs rely on local government support, nonprofit grants, and private donations, which often dry up during recessions. Some partners need to institute waiting lists or cut services to stay afloat. Others simply do not survive, creating major service gaps. The result is that there are fewer services at the same time more people need them.


The Department of Medical Assistance Service's High Needs Supports Benefit is a significant step toward alleviating these challenges. The benefit will provide a sustainable source of funding to supportive housing and employment organizations. It will help Medicaid enrollees' address their health-related social needs and ultimately improve health outcomes while reducing health care costs. VCU Health System thanks DMAS for advocating for this benefit through the Section 1115 waiver process.


HSN Benefit Program Considerations for Supportive Housing and Employment Entities


It is VCU Health System’s understanding that supportive housing and employment entities, not clinical providers, will primarily furnish the HSN benefits. To incentivize participation, VCU Health System urges DMAS to set adequate reimbursement rates for organizations furnishing supportive housing and employment benefits. It should also streamline reporting requirements to the minimum necessary to ensure program integrity. To participate in Medicaid, providers must keep detailed records, comply with HIPAA, and implement claims billing software among other costly requirements. If DMAS establishes inadequate reimbursement rates or overly burdensome administrative requirements, supportive housing and employment entities may not be able to justify the costs to participate in the program.


VCU Health System also urges DMAS to develop credentialing criteria for supportive housing and employment agencies that are not overly restrictive. This is critical because these organizations may not be able to participate in the program if the credentialing costs are too high. While VCU Health System acknowledges the importance of only credentialing qualified entities, it urges DMAS to set reasonable criteria and to do so in a transparent manner.


HSN Benefit Program Considerations for Clinical Providers


While VCU Health System expects supportive housing and employment entities will furnish the HSN benefits, clinical providers will be needed to identify Medicaid enrollees’ health-related social needs and navigate them to these entities. VCU Health System urges DMAS to consider the following questions as it implements the HSN benefit program:


  1. Under the program, MCOs will be responsible for screening Medicaid enrollees for housing and employment needs. However, clinical providers regularly screen patients for health-related social needs. Will there be a process for aligning these screening tools and data collection?


  1. In the table under Section XIV of DMAS’s HSN program policy paper, there is a notation that states “Identifying individuals eligible for High Needs Supports benefit through mechanisms such as claims and encounter data analysis.” However, there is no consistent mechanism for providers to identify health-related social needs. Does DMAS expect to require clinical providers to document ICD-10-CM Z Codes to identify housing and employment needs?


  1. MCO care coordinators and care coordinator extenders will be responsible for identifying eligible enrollees and navigating them to supportive housing and employment entities. Will DMAS allow MCOs to subcontract with clinical providers that conduct health-related social needs screenings to capture this information at the point of care? Will there be a process for clinical providers to refer patients to supportive housing and employment entities?


  1. Will Medicaid enrollees’ utilization of supportive housing and employment benefits be documented in a platform that clinical providers can access? Such access will be critical for clinical providers who focus on connecting patients with housing and employment resources as a part of their population health initiatives.


Finally, VCU Health System encourages DMAS to continue prioritizing the social determinants of health as it develops other payment and delivery policies. As mentioned above, doing so will improve beneficiaries' health outcomes and promote health equity.


Please do not hesitate to contact Karah Gunther, Executive Director of Government Relations and Health Policy, at or 804-828-6879 should you have any questions.

CommentID: 87411