The National Comprehensive Cancer Network (NCCN) held a policy summit at the National Press Club in Washington, DC, to highlight the importance of identifying the health-related social needs (HRSN) of patients as part of high-quality cancer care. Speakers and panelists contributed their views during the summit.
At the event, the NCCN presented new recommendations for screening and addressing HRSN in four core areas: transportation access, housing security, access to food, and financial security. The recommendations were developed by an NCCN multi-stakeholder working group co-chaired by Yelak Biru, MSc, President and CEO of the International Myeloma Foundation, and Loretta Erhunmwunsee, MD, Vice Chair of the NCCN Diversity, Equity, and Inclusion Directors Forum. The working group recommended that cancer patients should be screened for these core HRSN measures at least once a year and at care transition points (see NCCN.org/social-needs).
The recommendations call for a plan to address patients' needs after screening: "Screening without a plan to address the unmet need may further harm the patient." The recommendations also call for payers to reimburse for HRSN screening visits and discussions with a risk-adjustment payment for providers with a high-screen positive rate for HRSN in their patient population.
It is very important that the oncology community address "patient needs that extend beyond the examination room," emphasized NCCN CEO Robert Carlson, MD. He noted it is well-established in oncology that "outcomes are impacted significantly by factors outside the health care system." HRSN is defined as "an individual's unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of underlying social determinants of health," which are conditions in which people are born, grow, work, and age.
Biru said that, in addition to the four core high-impact measures the working group identified for screening, there are other HRSNs that can affect cancer care outcomes. These include social and caregiver support, utility assistance, paid sick leave, neighborhood and community safety, health insurance, digital connectivity, and health literacy. These needs may overlap and are often interrelated, he noted. Screening for HRSN "requires time and it requires money," Biru said. "But not doing it means the patient will not recover well."
The health care system was not previously designed with HRSN in mind, said Crystal S. Denlinger, MD, FACP, Senior Vice President and Chief Scientific Officer of the NCCN and incoming CEO of the organization. Therefore, she believes education, engagement, and advocacy will be necessary to make sure screening for and addressing HRSN are fully incorporated into high-quality care.
"Oncologists are focused on the treatment," Denlinger noted. But "health-related social needs-unmet economic and social conditions that affect an individual's ability to maintain health and well-being-must be accounted for as a standard part of multidisciplinary health care. I think all of these recommendations are doable" if both providers and payers recognize that "this is part of health care."
Value-Based Care
In a keynote talk, Ellen Lukens, MPH, Deputy Administrator and Director of the Center for Medicare and Medicaid Innovation (CMMI), highlighted CMMI value-based care models, noting a pillar of the center's models is advancing health equity. Lukens said the CMMI Enhancing Oncology Model, a voluntary 5-year program that launched this past July, has a requirement that participating oncology practices screen patients for HRSNs using several available tools. These include the NCCN Distress Thermometer and Problem List, the PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences) Screening Tool, and the Accountable Health Communities Screening Tool. "There is so much energy in the oncology community for transforming cancer care," she said.
Lukens noted that unmet social needs are common in the Medicaid population, with about 35 percent of beneficiaries experiencing housing instability, food insecurity, transportation problems, utility needs, or safety issues such as violence. In addition to national initiatives, a number of states are also addressing HRSN through Section 1115 waivers, which allow them to add non-clinical services to benefits packages. Lukens said that, looking to the future, CMMI will focus on HRSN screening, referral, navigation, and sharing resources and data to improve health outcomes.
An NCCN background paper noted that health systems are beginning to give health care organizations incentives to integrate HRSN screening into practice. For example, The Centers for Medicare and Medicaid Services (CMS) has proposed implementation of the quality measures "Screening for Social Drivers of Health" and "Screen Positive Rate for Social Drivers of Health" through a variety of CMS quality programs. Recognizing health care organizations' workforce shortages, burnout, and administrative burden, the background paper states the need to support HRSN screening "without undue burden on patients, caregivers, and providers."
"What is the cost of doing nothing?" asked Robin Yabroff, PhD, MBA, Scientific Vice President of Health Services Research for the American Cancer Society. "I would say that it's cost-effective [to screen]." She pointed out there is a business case for HRSN screening and acting on its results because it can avoid late diagnosis and preventable deaths. She cited subway cards as a cost-effective way to address a patient's transportation needs, for example. Reimbursement for HRSN is a critical component of its implementation, Yabroff noted.
David W. Baker, MD, MPH, FACP, Executive Vice President and Editor-in-Chief of the Joint Commission Journal on Quality and Patient Safety agreed. "We see this as a routine part of care. Oncology knows how to do hard things. This seems incredibly hard, [but] we can do this," he stated. For cancer patients, "If these health-related social needs are not addressed, they may not be able to adhere to treatment plans-meaning their health and even their life is threatened."
Baker stressed the need for community-based partnerships, such as with food banks. "We can't just make a referral" without these partnerships, he noted. For example, a food bank may be overwhelmed and run out of food.
When screening for HRSN, it is very important to do so with care and sensitivity, emphasized Eucharia Borden, MSW, LCSW, OSW-C, FAOSW, Vice President of Programs and Health Equity at Family Reach. She has spent hours sitting in examination rooms with patients who are too ashamed to talk about their social health needs, such as a lack of food.
"We can reduce the shame of HRSN by not shaming them in the beginning," she said, noting that the health-related social needs of patients "are not treated with the same respect as the treatment itself." She emphasized the need for building trust when talking to patients about their social health needs and noting it is the job of an oncology team member to guide patients to the right team professional to help them. "Where there is trust, people will speak about what their needs are," she said.
Alan Balch, PhD, CEO of the Patient Advocate Foundation agreed with this idea. Patients need to feel that HRSN screening is part of giving them the whole-person care they deserve, he said. They should not feel shame or stigma because of HRSN factors. "The humanity has to be there," he emphasized.
Because patients' needs change over time, it is important to have conversations about HRSN early and often, said Nadine Jackson McCleary, MD, MPH, Associate Professor of Medicine at Harvard Medical School and Senior Physician at Dana-Farber Cancer Institute. Helping patients with HRSN issues is "part of our humanity," she summed up.
Peggy Eastman is a contributing writer.