Your highest-risk patients qualify for a reimbursement most physicians have never heard of

If you ask most physicians in independent practices whether their practice bills for Community Health Integration (CHI) services, you’ll likely get a blank stare.

CHI services are Medicare billing codes that enable practices to get paid for solving their patients’ social needs. That means when practices assess what social needs their patients have, and coordinate and connect them to community-based resources that support adherence and outcomes, they can generate more revenue.

Health plans are actively funding these CHI codes today. However, the vast majority of eligible practices aren’t billing for them. In many cases, that’s because no one has told them the CHI codes are there or how to operationalize them. That awareness gap is larger, and more consequential, than most people realize.

Thanks to a peer-reviewed study published in NEJM Catalyst in March 2026, we can put real numbers behind this missed opportunity. In a program run by Elevance Health, researchers analyzed 15,050 high-risk members using a rigorous difference-in-differences methodology.

The study found that patients with both clinical and social risk factors saw a $181 per member per month (PMPM) reduction in total allowed costs when their social needs were addressed. That $181 cost reduction was a statistically significant result that exceeded the cost of the program itself. Meanwhile, for patients who only had clinical risk factors, the study found just a $40 PMPM reduction from the interventions, which is statistically insignificant.

In other words, analyzing the social risk layer isn’t a nice-to-have. It’s actually where all of the return lives. Health plans are now able to quantify that return, which in turn creates an opportunity for providers to unlock new revenue streams by addressing social needs directly.

The opportunity most practices don’t know they have

In the study population, just 32 percent of members (the group with both clinical and social risk factors) accounted for 100 percent of the statistically significant return on investment.

Right now, practices are already caring for those patients whose outcomes are driven by social needs. But being fully equipped to directly address those social needs is a different proposition.

With CHI, providers can be reimbursed for addressing the non-clinical barriers that shape whether patients can access and adhere to care: food insecurity, housing instability, transportation, and more. CHI represents an opportunity to generate $60 to $80 of revenue per 30-minute billing unit that practices simply aren’t capturing today.

For example, take a nephrology practice managing a panel of dialysis-dependent Medicare patients. The physicians know that missed treatments, transportation gaps, and inconsistent access to renal-appropriate nutrition are driving hospitalizations. However, today they have no structured way to intervene.

Through CHI, that same practice could be reimbursed to identify those barriers, coordinate transportation, connect patients to food resources aligned to renal diets, and support medication adherence. In other words, they could show value to their payers by enabling care at the lowest cost-of-care setting, for one of the highest-cost populations in Medicare. These efforts can also help generate revenue in between appointments.

Or, consider a primary care practice with a large population of Medicare patients managing multiple chronic conditions. A subset of those patients consistently misses follow-ups, struggles with medication access, and cycles through the emergency department. With CHI, the practice can be reimbursed to assess those social barriers, coordinate support, and ensure patients stay engaged in care, shifting utilization away from acute settings and toward more consistent, preventive management. Once again, the practice lowers costs for payers. Moreover, they are doing this while generating additional revenue for themselves and providing additional value to patients.

The real barrier lies in execution

If the opportunity is this clear, why aren’t more practices acting on it? Ultimately, it’s because CHI is not just a billing exercise, but an operational one.

To deliver these services effectively, practices need to be able to identify the right patients, assess social needs in a standardized way, intervene in a meaningful and personalized manner, and document outcomes in a way that supports reimbursement. The model validated in the study followed a structured approach: Identify the right patients, screen them using tools like PRAPARE, intervene directly, and then report outcomes.

Most practices don’t have the infrastructure to do this on their own, for many reasons.

First, the practices don’t usually have community-based care coordinators embedded in their workflows. Second, it’s hard to gain visibility into whether referrals to social services actually result in closed loops. And finally, they don’t have the bandwidth to build and manage those systems internally. As a result, the work either doesn’t happen, or it happens in fragmented, inconsistent ways that don’t translate into measurable impact.

This is where many prior “solutions” have fallen short. Giving patients a list of resources or access to a digital directory does not solve the problem. The study makes that clear: it was direct, hands-on intervention, not passive navigation, that drove results.

Benefiting health plans, patients and now providers

The model validated in the NEJM Catalyst study worked because it combined clinical oversight with community-based execution. Local, culturally aligned care coordinators engaged patients directly. They built personalized care plans for those patients, and connected them to vetted community resources. That work was integrated with clinical care, not separate from it.

Providers could enable this same model by forming the right partnerships and seeking out services that can integrate directly into their practices, without adding headcount or setting up entirely new systems internally.

Ultimately, CHI is an opportunity for providers to refocus on the core reasons they practice medicine in the first place: to help people, with human-to-human connections. Practices of course are already stretched thin, but the right partnerships can not only allow them to address social needs that make the biggest difference in people’s health, but also generate more revenue. Independent practices are under more financial pressure than ever; any opportunity to double down on their missions while generating sustainable revenue streams is one worth seizing.

Susan Rawlings Molina is the CEO and co-founder of GroundGame.Health.