Mandates and Incentives to Support Social Needs Screening—Challenges and Opportunities

Health-related social needs (HRSNs) are associated with poor and disparate child health outcomes, decreased access to preventive care, and increased acute care utilization.¹ There is, therefore, growing momentum around addressing HRSNs through social care integration in pediatric health care settings.

This enthusiasm is driven in part by mandates and incentives supporting HRSN screening, including Centers for Medicare & Medicaid Services (CMS) quality measures,² Joint Commission requirements,³ and modifications to the US News and World Report hospital rankings.⁴ Payers have also recently entered the social care landscape, with some state Medicaid agencies mandating that Medicaid managed care organizations (MCOs) screen for HRSNs and several Medicaid MCOs reimbursing health care practitioners for HRSN screening.⁵

Although pediatric health systems are increasingly implementing social care programs, there is no consensus around what role the health care sector should ideally play in addressing social adversity. Also, although HRSN screening mandates and incentives are intended to spur investment in social care and improve child health outcomes, they may have negative unintended consequences.⁶ Herein, we highlight 3 potential challenges associated with implementing regulatory mandates and insurer incentives for HRSN screening and suggest opportunities for innovation and improvement.

Redundancy in Screening

Regulations and mandates in support of HRSN screening may lead to redundancies in screening. In some states, Medicaid MCOs reimburse health systems for HRSN screening, while in other states, MCOs directly screen patients and caregivers for HRSNs. Insurers may also contract with care management entities to conduct screening. Thus, families may be screened in the health care setting and by Medicaid MCOs or their contracted care management team in addition to screenings in other locations, such as schools and social service agencies. Medicaid-insured adult caregivers may also be screened at their own appointments and then again at their child’s clinic visits.

Repeated screening may engender confusion and mistrust among families who are asked sensitive and stigmatizing questions across multiple settings. Redundancy in screening may be further exacerbated by the multiplicity of tools used to screen for social needs, as few studies have examined the validity of existing social needs screening instruments.⁷ This lack of consensus around screening tools may also make it challenging to compare screening implementation and outcomes across sites, although this is 1 of the stated goals of HRSN quality measure implementation.

As health systems and insurers increase engagement in social care, there is an opportunity to form more effective partnerships to mitigate redundancies. First, health systems and insurers must consider who is best poised to engage families around HRSNs and provide meaningful assistance. Health care practitioners often have established rapport with families and (ideally though not uniformly) have training in family-centered and trauma-informed care. However, insurers may be able to work across multiple health systems within a region and link social needs information for household members to minimize repeated screening. More patient- and family-centered research is needed to examine who is best poised to screen families and connect them to available resources.

Second, if both practitioners and insurers engage in screening, there must be a clear delineation of roles to reduce redundancy and avoid frustrating or traumatizing families. Third, if insurers or contracted agencies plan to engage in screening, there should be transparency around whether and how each involved entity will contact families and what training is in place to ensure representatives engage with families in a sensitive and trauma-informed way. Fourth, redundancies in screening across care settings could be reduced by using health or community information exchanges to integrate data across the health and social service sectors. Finally, as HRSN quality measures are implemented, more work is needed to achieve consensus around screening tools to reduce redundancy and increase the ability to track and compare quality metrics.

Underdeveloped Incentives to Support Resource Connection

While new requirements from the National Committee for Quality Assurance include metrics on HRSN intervention, the CMS has not yet incorporated standards that incentivize interventions, and many state Medicaid MCOs do not explicitly allocate funding for addressing HRSNs once they are identified.⁸ By disproportionately incentivizing screening, regulatory mandates risk creating a model where screening becomes another box to check to meet requirements, rather than a first step toward meaningful resource provision.

Several strategies could improve resource connection as screening mandates are implemented. Regulatory bodies should consider reimbursing for resource connection to incentivize health care systems to connect families who are interested in support to available resources. In addition, reimbursements could incentivize longitudinal follow-up with families, recognizing that many HRSNs are dynamic and require sustained navigation and support to resolve. This may require more sustainable funding for the social care workforce, including social workers and community health workers. Because many health systems already struggle to fund their social care workforce, implementing screening without additional investments could further outstrip capacity. In addition, particularly in the primary care setting, pediatric practitioners often have a mere 20 minutes for visits; thus, implementing screening with the expectation that screening and connection will be accomplished by the primary care practitioner during these brief clinical visits (instead of by a dedicated social care workforce) is unrealistic.

Regulators and insurers should also promote health and social service system integration. Funding could be directed to increasing enrollment in government benefit programs linked to improved health outcomes (eg, Special Supplemental Nutrition Program for Women, Infants, and Children, Supplemental Nutrition Assistance Program). Funding could also directly support community-based organizations to ensure they have the capacity to serve the growing number of families referred to them by health systems.⁹ Finally, alternative payment models could include novel arrangements in which health systems, insurers, and community-based organizations share financial incentives and accountability for health out-comes. Some of these strategies are already being tested through the CMS Accountable Care Organization Realizing Equity, Access, and Community Health and Integrated Care for Kids models.

Need for Documentation and Data Sharing Standards

Several regulators and insurers require that HRSN screenings are documented in the electronic health record to facilitate reimbursement. Although documentation may be necessary to meet these requirements, without adequate safeguards and communication with families, electronic health record documentation may lead to negative unintended consequences.

First, depending on how HRSNs are documented and shared (ie, clinical notes, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Z codes), they may be visible to caregivers via the patient portal. This issue is particularly complicated in pediatrics, as children may have more than 1 adult proxy who can access their health portal. Thus, if 1 caregiver discloses a need (eg, intimate partner violence), it could result in inadvertent disclosure to the other caregiver. Second, if caregivers view HRSNs documented in their child’s medical record but did not anticipate that this information would be documented and shared, it may fracture trust between families and practitioners. Third, documented HRSNs may influence how health care practitioners view and communicate with families¹⁰ and could contribute to increases and/or inequities in referrals to child protective services for poverty-related needs. This could negatively impact families’ willingness to engage in future social needs screening or even to seek needed medical care for their children.

As regulators and insurers navigate the realm of social care, there are opportunities to proactively develop best practices for documentation and data sharing. These could include the following: (1) informing all families that HRSN information may be documented in their child’s medical record; (2) ensuring that HRSN data provided by 1 parent or caregiver can be hidden from other proxies; (3) training practitioners on trauma-informed screening, response, and potential bias related to HRSN screening; and (4) tracking balancing metrics, including child protective services referrals.

Conclusions

Regulators and insurers have entered the social care landscape, and this trend will accelerate in the years to come. Now is the time for regulators, payers, pediatric health systems, and community organizations to proactively define their roles, invest in resource connection, and establish data sharing and documentation standards. Forging ahead without addressing these key challenges risks compromising families’ trust and safety. Integration of social care into health care has the potential to improve health outcomes and address health disparities, but successful implementation will require collectively confronting these challenges.