Recently, an elderly patient at my practice unexpectedly began to miss her monthly appointments.
I was alarmed. The patient has atrial fibrillation—a condition characterized by irregular heart rhythms and an increased risk of stroke. The condition demands consistent and timely medical care. For elderly patients like the one in our care, these appointments are not just check-ups. They are vital for adjusting medications, monitoring heart health, and preventing serious complications like blood clots.
Yet, despite how crucial these appointments were, I discovered that this patient faced a significant challenge: she could not access a car or reliable transportation to our office.
What I am describing is not new. All patient care is affected by “drivers of health” or “social determinants of health”—meaning factors that significantly influence health outcomes, such as access to food, stable housing, and reliable transportation. Physicians encounter patients who face similar hurdles every day, from skipping meals to feed their families to struggling with housing due to exorbitant rent prices.
With our focus on preventive care and frequent patient interactions, primary care settings are especially well-positioned to address drivers of health. By integrating these screenings into my practice, I have been able to better understand and meet my patients’ unmet social needs and deliver better health care that accounts for the realities of their lives.
Unfortunately, screening our patients for drivers of health can seem like a daunting task. Primary care physicians are facing a myriad of issues, including staffing shortages, increasing administrative burdens, and rising costs.
But by implementing evidence-based approaches to addressing drivers of health in clinical care settings, we can safeguard patients’ health while bolstering the sustainability of our practices. Here’s how my small, independent primary care practice found the support and resources to make these solutions more seamless.
Primary care practices can leverage new Medicare reimbursement codes to address drivers of health
Remember the patient with atrial fibrillation I mentioned earlier? She lives on a fixed income, so we initially chose the less expensive treatment option—which also requires monthly appointments and greater reliance on transportation.
When we discovered her transportation issues, we tailored a solution to meet her needs. Instead of scheduling separate visits throughout the month, we consolidated her appointments into fewer trips and utilized nearby lab facilities as much as possible, so she received necessary medical care while streamlining the logistical challenges of accessing our clinic. Redesigning her clinical care to account for this driver of health—in this case, transportation—helped improve the continuity of her care.
Making these kinds of adjustments to support patients struggling with transportation and other drivers of health can be time-consuming for our already-strapped clinic staff. But with the introduction of new drivers of health-related G codes in November 2023, the Centers for Medicare and Medicaid Services (CMS) has taken a crucial step to ensure that physicians have the resources to perform these screenings and provide custom solutions to each patient facing obstacles that would impact their clinical care and health outcomes. These codes, such as G0136—which allows physicians to bill for drivers of health assessments—and G2211—which covers ongoing primary care—helped my practice create a more efficient process for addressing these barriers.
For our patient with atrial fibrillation, we used these new G codes to bill for the time spent assessing her transportation challenges and finding a solution that ensured she could continue to receive high-quality clinical care. In addition, these reimbursement codes meant we could allocate more resources toward our clinic staff’s compensation, both to recognize the challenging and important work they do on behalf of patients and to support staff retention in the long run.
All in all, patients gain better access to high-quality, cost-effective care and reduce the stress of managing their conditions. Physicians and staff, meanwhile, receive the support they need to meet patients’ needs.
The policy landscape increasingly supports drivers of health screening in clinical practice
While screening for and addressing drivers of health as part of our clinical workflows can initially seem daunting, primary care practices can transform these challenges into actionable insights that drive personalized care. From leveraging Medicare reimbursement codes for drivers of health to utilizing robust referral networks of community resources, we can pave the way for comprehensive patient support beyond medical treatment alone.
Increasingly, actionable recommendations and policy advancements enable this by addressing drivers of health to improve patient care and outcomes, reduce costs, ease the load on physicians, and slash administrative burdens. These new G codes, for example, are consistent with CMS’s recent enactment of the first-ever drivers of health measures in federal payment programs and its commitment to establishing a “universal foundation” of quality measures—including drivers of health screening and intervention measures—to enable consistent data across federal health care payment programs and reduce the burden on providers.
These efforts mean federal health care programs are increasingly measuring—and paying for—what truly matters to physicians and their patients, including improving health outcomes, enhancing drivers of health data collection, and reducing our practices’ administrative hurdles.
Ripley Hollister is a family physician.
