Social determinants of health (SDOH), the conditions where people are born, live, learn, work, play, worship, and age, have a profound influence on kidney health outcomes. Amid a growing recognition of health disparities, the Centers for Medicare & Medicaid Services (CMS) released the Framework for Health Equity 2022–2032 outlining five priorities across health care settings: (1) expand the collection of SDOH data, (2) assess and address health care disparities, (3) build capacity to reduce disparities, (4) advance language access, health literacy, and culturally tailored services, and (5) increase accessibility of health care.1 For patients with kidney disease, specifically, the ESRD Treatment Choices (ETC) Model and Increasing Organ Transplant Access (IOTA) Model include health equity incentives designed to reduce socioeconomic disparities in access to home dialysis and kidney transplantation. In parallel, CMS recently implemented transformative policy changes to assess and address SDOH among patients with kidney disease. In this article, we comment on those changes to the ESRD Medical Evidence Report (Form CMS-2728), ESRD Quality Incentive Program (QIP), and CMS Physician Fee Schedule (Table 1).
Table 1.
Policy changes to address social determinants of health in the ESRD Medical Evidence Report (Form Centers for Medicare & Medicaid Services-2728), ESRD Quality Incentive Program, and Centers for Medicare & Medicaid Services Physician Fee Schedule
| Regulatory Change | Details |
|---|---|
| ESRD Medical Evidence Report (Form CMS-2728) new questions2 , a | |
| Housing insecurity | 23. Are you currently concerned about where you will live over the next 90 d? |
| Caregiver support | 24. Do you have caregiver support to assist with your daily care? With home dialysis/kidney transplant? Does the caregiver live with you? |
| Access to reliable transportation | 25. Do you have access to reliable transportation? |
| English proficiency | 26. Do you understand health literature in English? Do you need a different way other than written documents to learn about your health? Do you need a translator to understand health information? |
| Financial strain | 27. Do you find it hard to pay for the very basics like housing, medical care, electricity, and heating? |
| Food insecurity | 28. Within the past 12 mo, has the food you bought not lasted and you did not have money to get more? |
| Interpersonal safety | 29. Has anyone, including family and friends, threatened you with harm or physically hurt you in the last 12 mo? |
| ESRD QIP new quality measures3 | |
| Facility commitment to health equity reporting measure | • This structural measure assesses facility commitment to health equity using a suite of equity-focused organizational competencies aimed at achieving health equity for racial and ethnic minority groups; people with disabilities; members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community; individuals with limited English proficiency; rural populations; religious minorities; and people living near or below poverty level. Facilities will receive two points each for attesting to five different domains of commitment to advancing health equity for a total of ten points • Measure comprises 2.0% of a facility's TPS. For calendar year 2025, the TPS is scored of 100 and financial penalties begin at a TPS of 50 • Hospitals also report on this measure in the Hospital Inpatient Quality Reporting Program |
| Screening for social drivers of health reporting measure | • “Percentage of patients at a dialysis facility who are 18 yr or older screened for all five HRSNs (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety)” • Facilities may choose which screening tool to use • Data reported using the ESRD Quality Reporting System • Measure comprises 1.43% of a facility's TPS. Reporting on the measure is not mandatory • Patients may opt-out of screening • Publicly reported on the Care Compare website |
| Screen positive rate for social drivers of health reporting measure | • “Percentage of patients at a dialysis facility who are 18 yr or older screened for all five HRSNs, and who screen positive for one or more of the following five HRSNs: food insecurity, housing instability, transportation problems, utility difficulties, or interpersonal safety” • Measure comprises 1.43% of a facility's TPS. Reporting on the measure is not mandatory • The proportion of patients who screen positive for each HRSN will be reported • Patients may opt-out of screening • Publicly reported on the Care Compare website |
| CMS Physician Fee Schedule new reimbursements4 | |
| CHI service reimbursement | • HCPCS Codes G0019 (1.00 wRVU, approximately $80), G0022 (0.70 wRVU, approximately $50) • Services should be 60 min • CHI services include person-centered assessment, care coordination, health education, building self-advocacy skills, and health system navigation • Can be furnished monthly—only one provider can bill CHI services per calendar month • Requires written or verbal consent documented in the medical record • Part B cost sharing rules apply • Can be delivered via telehealth • Community health workers, care navigators, and other auxiliary personnel may be employed by CBOs |
| PIN service reimbursement | • HCPCS Codes G0023 (1.00 wRVU, approximately $80), G0024 (0.70 wRVU, approximately $50), G0140 and G0146 for peer support for patients with behavioral health conditions • Focused on patients with severe, high-risk illnesses but not necessarily SDOH needs • Navigation services are provided by auxiliary personnel such as community health workers and care navigators • Requires supervision by the billing practitioner • Auxiliary personnel must meet state requirements for certification or training requirements in the competencies outlined by CMS • No current PIN certification for kidney disease • Part B cost sharing rules apply • Can be delivered via telehealth |
| SDOH Risk Assessment reimbursement | • HCPCS code G0136 (wRVU 0.18, approximately $19) • Services should be 5–15 min, not more often than every 6 mo • Should use a standardized, evidence-based tool (examples include AHC, PRAPARE, and the Medicare Advantage Special Needs Population Health Risk Assessment) • Must include food insecurity, housing insecurity, transportation needs, and utility difficulties • Social needs must be documented in the patient's medical record • May be performed by physicians, advanced practice practitioners, social workers, or auxiliary personnel under supervision • Must be done on the same day as an E&M visit • Use of ICD-10-CM Z codes (Z55–Z65) is optional and can influence the level of medical decision making for E&M coding • Can be delivered via telehealth |
AHC, Accountable Health Communities; CBO, community-based organization; CHI, community health integration; CMS, Centers for Medicare & Medicaid Services; E&M, evaluation & management; HCPCS, Healthcare Common Procedure Coding System; HRSN, health-related social need; ICD-10-CM, international classification of diseases-10-clinical modification; PIN, principal illness navigation; PRAPARE, Protocol for Responding to and Assessing Patients' Assets, Risks & Experiences; QIP, quality incentive program; SDOH, social determinants of health; TPS, total performance score; wRVU, work relative value unit.
All questions answered as yes or no.
ESRD Medical Evidence Report (Form CMS-2728)—New SDOH Collection Requirements
Until recently, there were no regulatory requirements for dialysis facilities to collect SDOH in a standardized fashion or report SDOH to the federal government. In 2023, CMS revised Form CMS-2728 to include several new SDOH questions.2 These questions assess for housing insecurity, caregiver support, access to reliable transportation, English proficiency, financial strain, food insecurity, and interpersonal safety.
We believe the new Form CMS-2728 offers a tremendous opportunity for data collection and research, but evaluation is needed to assess its impact on patient care. The new questions will allow for national prevalence estimates of health-related social needs among patients with incident ESKD, as well as research examining the association of social needs with hospitalizations, readmissions, mortality, and other outcomes. By assessing SDOH using standardized questions, some dialysis facilities may identify social needs earlier, facilitating referrals to community-based organizations (CBOs).
ESRD QIP—New SDOH Quality Measures
Three new quality measures are being added to the ESRD QIP to advance health equity and standardize SDOH data collection.3 In calendar year 2024, facilities will receive points for reporting their facility commitment to health equity by attesting to five domains: (1) equity is a strategic priority, (2) data collection, (3) data analysis, (4) quality improvement, and (5) leadership engagement. Given disparities in home dialysis, kidney transplantation, vascular access, bloodstream infections, and patient experience scores among patients with ESKD, having dialysis facilities attest to these domains may prompt them to implement interventions to reduce these disparities.5 However, as a self-reported checkbox measure, CMS will likely be unable to enforce whether facilities are meaningfully participating in these activities.
In calendar year 2025, two additional reporting measures will be added to the ESRD QIP: (1) screening for social drivers of health and (2) screen positive rate for social drivers of health. These measures, in part, stem from the Center for Medicare and Medicaid Innovation's Accountable Health Communities (AHC) Model, which screened over 1 million Medicare and Medicaid beneficiaries for health-related social needs. Thirty-seven percent of patients had at least one social need, of whom over one third had at least one social need resolved after being connected to community services.6 Given these promising results, dialysis facilities will be expected to screen patients yearly for five core health-related social needs: food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.
These new SDOH quality measures will provide valuable data to allow researchers and policy makers to assess the facility-level burden of social needs and their association with quality of care and health outcomes. Dialysis organizations may be able to better tailor social worker–to–patient ratios and other resources toward dialysis facilities with a greater burden of social needs. CMS may use this information to adjust reimbursement toward facilities and/or patients with more social needs.
CMS Physician Fee Schedule—New SDOH Reimbursement
While the aforementioned changes focus primarily on SDOH data collection, CMS has finalized three new reimbursements within the Physician Fee Schedule to address SDOH.4 Unlike the ETC Model and IOTA Model health equity incentives, these reimbursements provide direct compensation for services rendered to address SDOH. Community Health Integration (CHI) reimburses for services that aim to resolve unmet social needs that are affecting a patient's medical care. CHI services are typically provided by community health workers, care navigators, or other certified personnel who may be culturally and language concordant with patients. For example, nephrology practices seeing patients with late-stage CKD may bill for CHI services to connect patients with housing or transportation resources, improving their ability to receive home dialysis and attend medical appointments.
Principal Illness Navigation (PIN) services help guide patients with a serious, high-risk condition (including kidney disease) through their disease-specific care plan. There is evidence that navigation services are effective: In the AHC Model, navigation, compared with referral alone, resulted in an 8% reduction in emergency department visits, although there was no change in hospitalizations or total expenditures.6 PIN services may help patients with late-stage CKD navigate the complicated transplant evaluation process. Community health worker interventions similar to CHI and PIN services for patients with kidney disease are increasingly being tested and are a major focus of initiatives through the National Institute of Diabetes and Digestive and Kidney Diseases to address structural racism.7,8
The SDOH Risk Assessment reimburses providers for using a standardized, evidence-based tool to assess for five core health-related social needs. Unlike SDOH data collection on Form CMS-2728 and in the ESRD QIP, the SDOH Risk Assessment is not used for routine screening, but rather when a practitioner suspects there are unmet social needs that may interfere with medical diagnosis or treatment.
Implementation Challenges
While offering the potential to improve patient care and research, these new policy changes come with implementation challenges at the system, facility, clinician, and patient levels. Without a strong network of CBOs with the requisite capacity, SDOH screening requirements may fall short of their goal of improving patient-centered outcomes. Dialysis facilities will have to adjust their workflows, staff training, and electronic health record systems to facilitate collecting standardized SDOH information for both Form CMS-2728 and ESRD QIP measures, as well as to initiate closed-loop referrals to CBOs. The new requirements impose additional unfunded administrative burdens on dialysis facility administrators, social workers, and nephrologists, during a time when facilities are already facing staffing shortages in the setting of the coronavirus disease 2019 pandemic. There is concern that increased documentation requirements may divert clinician time away from delivering patient care. Reimbursements for CHI and PIN may not be sufficient for nephrology practices to employ their own staff, so shared models may be needed. At the patient level, the AHC health-related social needs questions have not been widely validated among patients with ESKD, and patients may be hesitant to disclose their social needs without a full understanding of how the information will be used.9,10 More fundamentally, leading experts have questioned whether health care facilities are the most efficient or cost-effective settings to assess for social service needs.11
In summary, recent policy initiatives to expand SDOH data collection for all incident and prevalent ESKD patients nationwide may facilitate addressing unmet social needs and will greatly enhance research. New reimbursements to connect patients with community resources and support them with health care system navigation offer a real opportunity to surmount barriers to high-quality kidney care. In concert with health equity provisions of value-based payment models, such as the ETC Model and IOTA Model, these initiatives are promising steps forward as part of CMS's comprehensive Framework for Health Equity, but evaluation is needed to assess their impact on clinical outcomes.
Acknowledgments
The authors acknowledge the valuable perspectives of the American Society of Nephrology Quality Committee and Health Care Justice Committee who provided public comments to the Centers for Medicare & Medicaid Services on these policy changes. Because Dr. Lilia Cervantes is an Associate Editor of JASN, she was not involved in the peer-review process for this manuscript. Another editor oversaw the peer-review and decision-making process for this manuscript.
The content of this article reflects the personal experience and views of the authors and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or JASN. Responsibility for the information and views expressed herein lies entirely with the authors.
Disclosures
Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/JSN/E821.
Funding
S.L. Tummalapalli: Agency for Healthcare Research and Quality (K08HS028684) and Dalio Center for Health Justice. L. Cervantes: National Institute of Diabetes and Digestive and Kidney Diseases (U01DK137272, R01DK13722, and K23DK117018) and Colorado Behavioral Health Administration.
Author Contributions
Conceptualization: Sri Lekha Tummalapalli.
Investigation: Lilia Cervantes, Andrew Lu, Sri Lekha Tummalapalli.
Project administration: Lilia Cervantes.
Writing – original draft: Sri Lekha Tummalapalli.
Writing – review & editing: Lilia Cervantes, Andrew Lu, Sri Lekha Tummalapalli.
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