It’s time for Medicare to fund community-clinical partnerships, NASEM committee says

Medicare leaders should rethink how the federal government pays for and supports partnerships between primary care physicians and community organizations that promote patient health.

“Using Community Partnerships to Inform the Prevention Strategy of the Center for Medicare and Medicaid Innovation,” was published by the National Academies of Science, Engineering and Medicine. It is rooted in deliberations of the academies’ Standing Committee on Primary Care, established to help inform health policy and advise policymakers on the science and evidence behind proposals they are considering. It grew directly out of a request from Medicare to review the evidence on community-clinical partnerships and whether new payment and policy approaches are warranted.

Two of the report's co-authors spoke with Medical Economics about the findings: Alex H. Krist, M.D., M.P.H., a professor of family medicine at Virginia Commonwealth University, and Andrea A. Anderson, M.D., M.Ed., FAAFP, a family physician and associate professor at George Washington University School of Medicine and Health Sciences. Along with their academic roles, both remain in practice as family physicians.

They spoke frankly about the gap between what happens inside the exam room and what shapes their patients' health the rest of the time. The report includes conclusions drawn from real-world hits and misses by programs that might serve as examples for creating future community-clinical partnerships.

This transcript has been edited for length and clarity.

The report opens with a formal definition of community-clinical partnerships. Can you walk us through it?

Andrea A. Anderson, M.D., FAAFP: We talked a lot about how to actually define these partnerships, because we saw so many different examples in the literature and in our own experience about how they can work. What we came down to is that these partnerships are varied, and they should be. They should be crafted to meet the needs of the community they intend to serve. They can range from informal linkages and closed-loop referral systems to formal agreements and many other models — but always with the goal of supporting the intent of the clinician with the supportive environment and services that community partners can provide.

One of my favorite professors during residency used to point out that even if a patient comes in six times a year — which is a lot — that’s only about an hour and a half to two hours of their life spent in front of their physician. More of their time is spent in their community: at their faith-based organization, their community center, living their daily lives. This is our opportunity to maximize that community familiarity and achieve our shared clinical goals.

Alex H. Krist, M.D., M.P.H.: When we looked at what makes partnerships effective, three things stood out as truly critical. First, you need a clinical care system genuinely committed to partnering with a community organization. Second, you need a community-based organization that has the actual capacity to support a clinical partner. And third, you need bridging and navigation services — that can include dedicated people like community health workers or care navigators, as well as digital infrastructure to seamlessly connect both sides.

The report identifies seven common elements for effective and sustainable community-clinical partnerships. The first is a shared vision and population health orientation. How does that actually get started in practice?

Alex H. Krist, M.D., M.P.H.: There are a lot of different ways it can originate. One example in the report is the Nuka System of Care in Alaska, which is part of the Indian Health Service. It really emerged from the community leading the health system, to the extent that its members refer to themselves as the patient-owners of the system. That is a very concrete example of a community-led partnership.

But these partnerships can also emerge very practically. A clinician group can identify a specific need they are struggling to meet. As Dr. Anderson pointed out, people spend most of their lives outside the health care system — at work, at home, in their communities. When we start to identify the supports our patients need that the health care system is not equipped to provide — around social needs, around health behaviors — finding that gap can be the catalyst. And it can originate from the community side as well. Community organizations should also be approaching health systems and clinical practice groups with the idea of developing partnerships.

What is ultimately important is getting on the same page. It is not just about referring from one setting to another. It is about having a shared mission — working together to do something for the people you both serve. A mission statement can be a useful framing. It does not have to be that formal, but being aligned so that you are drawing out the synergies and the best of what each organization has to offer — that is what we are calling for.

Andrea A. Anderson, M.D., FAAFP: That bidirectionality is so important. One of the examples we examined was the Accountable Health Communities model — a CMMI (the Centers for Medicare & Medicaid Innovation Center) demonstration project. It showed that the need for sustained communication between organizations is real, because needs change. We may have screened patients six months or a year ago, but now a different need has emerged. People’s lives are dynamic, and effective partnerships have to be flexible enough to reflect that.

The Accountable Health Communities model ran from 2017 to 2023 and generated more than $200 million in net savings. The report drew a strong conclusion from those results. Can you explain what that conclusion means?

Andrea A. Anderson, M.D., FAAFP: We were in strong support of the clear evidence shown by this model. It demonstrated that these partnerships can work and can produce a real cost benefit. The model employed systematic screening and rescreening of patients to ensure their needs were still being addressed, and used community resources to best support them. It really reflects both a genuine innovation and a full-scale model showing this can work at a large scale.

Alex H. Krist, M.D., M.P.H.: One of the most important things about how the legislation governing CMMI works is this: if CMS runs a demonstration project through its Innovation Center and is able to show that it led to improved health outcomes at no increase in cost, or better yet at reduced cost, then CMS has the statutory authority to more broadly scale what was tested. The Accountable Health Communities model showed reductions in hospitalizations and emergency department visits and saved $200 million. In our view, that means CMS has now met those statutory thresholds. The time has come to roll this model out more broadly so that health systems, accountable care organizations (ACOs — provider-led organizations accountable for the quality and cost of care for a defined patient population), and clinical practice groups across the country can create similar partnerships and deliver similar benefits to their communities.

Andrea A. Anderson, M.D., FAAFP: We also wanted to emphasize the importance of upfront investment — not just waiting for the savings. Community partner organizations need real, sustained resources to get programs started and keep them running. I am sure Dr. Krist and I have both experienced the frustration of a promising community program that loses its funding after six months or a year. That instability hurts patients. Our recommendations call for sustained investment because sustainability is what converts a promising pilot into lasting improvement for a community.