Even as the concept of incorporating the social determinants of health (SDOH) into how the leaders of patient care organizations care for individuals inside the U.S. healthcare system, a team of healthcare policy researchers is arguing that federal healthcare policy leaders and policymakers need to think in more refined, nuanced ways, if they are going to find effective ways to use the Medicare system and other payment systems to reward providers for caring for those in need.
That is exactly what Robert L. Phillips, Jr., Andrey Ostrovsky, and Andrew W. Bazemore argue in their article, entitled “Adjusting Medicare Payments For Social Risk To Better Support Social Needs,” published in the Health Affairs Blog on June 1. Importantly, they draw a key distinction between basing payment differentials on data drawn from individuals at risk or in need—which they argue only further disadvantages those individuals—and making changes to the payment system based on micro-geographic assessments of social risk.
Phillips is founding executive director of the American Board of Family Medicine Foundation Center for Professionalism and Value in Health Care (Washington, D.C.); Andrey Ostrovsky has served on several boards and committees dedicated to behavioral health, interoperability standards, quality measurement, and home and community-based services; and Andrew W. Bazemore is the senior vice president for research and policy at the American Board of Family Medicine and co-director of the American Board of Family Medicine Foundation Center for Professionalism and Value in Health Care (Washington, D.C.).
As the article’s authors write, “Social determinants of health have greater influence on health than does health care, yet Medicare and most other payers have yet to adjust payments to better support the capacity of health care providers to address social needs. The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act directed the secretary of Health and Human Services (HHS) to review evidence linking social risk with performance under existing federal payment systems and to suggest policy options. In response, HHS produced two reports and commissioned a series of five additional reports from the National Academies of Sciences, Engineering, and Medicine (NASEM). The second HHS report suggests that area-based (or, geographically based) measures of social deprivation could play a role in payment adjustment.”
As they note, “The goal of social-needs payment adjustment is to use a reliable, defensible, and transparent mechanism to increase resources to clinics based on the social risk of their patient population, and to align this mechanism with processes that enables clinics to identify at-risk patients who can benefit from those resources. To advance these goals and seek consensus around a policy use case for incorporating social risk into federal payment systems, we convened a diverse group of stakeholders for a policy design workshop. The workshop produced consensus on a demonstration model for a payment adjustment based on a census-tract social deprivation index.”
Interestingly, the researchers write, “Use of social risk factors to inform payment for health care is not novel, and neither is using area-based measures. England and New Zealand currently use small area-based social risk indices to adjust federal resources for health care and social services…. The goal in the UK, as in New Zealand, is to increase resources to those caring for deprived populations to improve health equity. The US has developed related indices of social risk constructed for their ability to predict meaningful differences in cost, health care use, disease prevalence, and mortality. These US indices include the Social Deprivation Index and the Area Deprivation Index, which are available for every census tract in the country. Massachusetts already adjusts Medicaid payments using the Neighborhood Stress Score.”
When looking at the options, the authors write, “The use of small-area-based indices of social risk increases the likelihood of aligning health care resources with population needs in the most reliable and transparent manner. Reliability relates to knowing that what is being measured is consistent in assessing risk in all neighborhoods. Transparency means that stakeholders have clear understanding of the data used to adjust their payments. The use of small-area-based indices of social risk increases the likelihood of aligning health care resources with population needs in the most reliable and transparent manner. Reliability relates to knowing that what is being measured is consistent in assessing risk in all neighborhoods. Transparency means that stakeholders have clear understanding of the data used to adjust their payments.”
On the other hand, they say, “The alternative, collecting social needs data from individual patients, is more likely to disadvantage already disadvantaged patients whose social situations are often in flux and who are less likely to access care regularly and thus less likely to report their needs. Peter Smith, emeritus professor of health policy and global health economics at the University of York, helped develop the current payment adjustment process in the United Kingdom and explained at a British Embassy event that the use of small-area deprivation indices was partly based on his team’s own finding that patient-level collection disadvantaged the most deprived neighborhoods for precisely these reasons. We would expect to see similar dynamics play out in the US,” they write.
The researchers cite five elements that CMS could effectively use to account for social risk in CMS payments. They are:
> Adjustment for social needs, with a goal of resolving patients’ social risk and supporting community interventions;
> proportionality to area disadvantage, designed to address, social needs, not solely healthcare costs;
> geographic, small-area indices that are created based on patient and population outcomes, as a viable, reliable, sustainable mechanism for payment adjustments;
> reduced burden of social risk capture for providers, payers, states; reduced inequities between states created by the current environment in which states must propose a method of payment adjustment to federal partners in order to have any process;
> predefined goals of reduced total cost and improved patient health outcomes used to titrate funding rather than simply looking for cost offsets that do not align with accountability or expectations of meeting social needs.
The authors make it a point to delve into linguistic distinctions. They note that “Other recent Health Affairs blog posts have made the distinction between ‘social needs’ and ‘social determinants,’ or ‘community drivers of health,’ and the need to address both. Research has shown that assessing social risk can be achieved on a population scale, while social needs are particular to patients and communities and require on-the-ground assessment. Drawing these distinctions is important because addressing social needs at the individual level is unlikely to be enough to compensate for the impact of community social risk factors. Health care providers need to be agents of addressing social determinants at both levels, a capacity called community-oriented primary care, which was the foundation of community health centers in the US. To enable practices to address social risks and needs, payments need to reflect the costs of caring for deprived patients and the deprived communities in which they live. To develop the capacity to address community drivers of health, providers will require payment adjustment consideration beyond accounting for individual social risk or related costs.”
