The National Quality Forum is chipping away at the idea of payment as a key part of social determinants of health programming.
Despite the competing concerns within the healthcare industry, stakeholders have come to nearly one single conclusion: that the social determinants of health are key factors in patient health.
A patient’s social circumstances, including socioeconomic status, educational attainment, housing status, or food security, can have considerable impacts on their health outcomes. After all, if a patient cannot afford a treatment or access the healthy resources necessary to manage an illness, the clinical effectiveness of care decreases, researchers and clinicians agree.
But simply coming to agreement about the importance of the SDOH isn’t enough, according to Shantanu Agrawal, MD, the CEO of the National Quality Forum. As healthcare payers, providers, and policymakers learn more about the social factors that impact a patient’s health, they must ask themselves, “what’s next?”
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The healthcare industry has a few good plans underfoot that hold promise to address these social risk factors, Agrawal told PatientEngagementHIT.com in an interview. A recent move from the Centers for Medicare & Medicaid Services to allow Medicare Advantage plans to cover certain services that would address beneficiary social health are a positive step forward, Agrawal said.
“What CMS is no doubt hearing from a number of sources is that because these social risk factors have an impact on health outcomes, there ought to be a way of addressing those social risk factors and essentially utilizing healthcare dollars to address these needs,” he explained.
The CMS regulation will allow plans to offer supplemental benefits that cover meal delivery, rides to the grocery store, or a service that would make a patient’s home environment more conducive to healthy living. For example, Medicare Advantage plans may now cover the costs of an air filter for a patient living with asthma.
It’s this kind of experimentation that will help uncover a path forward, Agrawal noted. Instead of talking about the social determinants of health, organizations need to design programs – ones that have an equal chance of failing as they do succeeding – to establish an evidence base.
“It’s really beneficial to start experimenting with which approaches to dealing with social risk actually work,” Agrawal said. “Opening it up in the MA marketplace makes a lot of sense. This allows plans to take different approaches to work with their networks and providers and patients or beneficiaries to hopefully try lots of different approaches and actually see what works.”
There is still so much to learn about how to address social risk factors. For one, healthcare policymakers are essentially at a loss for who should pay for these services. Expanding the social safety net costs money, but there is little consensus about where that money should come from.
While some hospitals do have obligations to serve their communities as a part of their non-profit status, standard approaches to doing so can often be unclear, making their programming ultimately less impactful.
What’s more, there needs to be a broader approach engaging more healthcare stakeholders in community health payment programs. Healthcare dollars should certainly be funneled into community health programming, Agrawal said, but it should not be limited to hospital funds. That is what is so exciting about the new Medicare Advantage announcement and is fueling some of NQF’s latest projects.
Their Social Determinants of Health Payment Summit, being held in August this year, aims to uncover the best payment solutions addressing the SDOH.
“Payment matters a lot, and how we are utilizing healthcare payment can be really impactful,” Agrawal explained. “NQF is actually convening a large payment summit in August of this year to really help address this question. And not only call the community to action in terms of helping to finance interventions in the social determinants of health, but also trying to surface what really works based on the evidence and data, and the experiences of our committee.”
Payers, providers, and other medical industry leaders have a significant role to play in establishing a payment structure for the SDOH, Agrawal said, and industry collaboration will be essential to doing so.
In addition to exploring who will pay for SDOH programming, Agrawal said NQF is looking at how to drive equity in implementing programming. It’s been established that systems that support the social safety net costs money, and the fact of the matter is money is concentrated in certain areas in the healthcare industry.
Larger, academic institutions are simply going to have more means to build out social programming than a federally qualified health center (FQHC) will, despite the fact that the FQHC could considerably benefit from those programs.
NQF is trying to build out its guidelines with that knowledge, creating tools that will help any organization address the SDOH, Agrawal said.
“When we put forward, whether it’s quality improvement or population health improvement resources, we build into them different models or approaches that health delivery systems can take based on where they are today,” he explained.
For example, health systems that have no food insecurity program can learn how to get one started, while another with a mature program can learn how to assess and make improvements.
“Part of why we’ve taken on this payment summit was to align the community around what works in payment, so that we are helping to address all of the dimensions, or at least as many of the dimensions of this problem that we can,” Agrawal said, acknowledging the multistakeholder approach NQF is taking to the summit.
Involving more stakeholders allows NQF to create programs and guidelines that apply to multiple different types of organizations, not just the well-endowed.
But the challenges go beyond who will pay for SDOH interventions. As healthcare organizations realize the impact SDOH can have on outcomes, they are debating how clinical quality measures should be risk-adjusted.
This debate is multifaceted and brings about several good arguments, Agrawal acknowledged.
On the one hand, risk-adjusting for SDOH can create fairer reimbursements.
“There’s a strong argument to be made about leveling the playing field between providers, just as we have done with clinical risk factors,” Agrawal stated. “If you’re living in a community and serving the community that faces a lot more social risk factors, that should somehow be addressed by the measurement enterprise. That way providers are being compared in a more appropriate way with delivery systems or providers that are generally working in populations with lower social risk.”
“But the concern is that we don’t want to lower the standards for populations that already face social risk challenges,” he continued. “If patients are socioeconomically worse off, if they have fewer access to resources, if they don’t have health insurance, would risk adjusting for those kinds of risk factors actually disadvantage them even further?”
There is no good answer, at least yet, Agrawal said. Part of the problem is the overlap between many clinical and social risk factors. Take age, for example. Age is often regarded as a clinical risk factor. After all, older adults have a higher chance of developing a chronic illness or experiencing an injury that could eventually impact their health.
But age is also a social risk factor, although it’s not usually treated that way.
“We also know that older people in our society have fewer financial resources generally than younger people, that they suffer from social isolation, that they may not get the nutrition that they need,” Agrawal said. “That’s why we have programs like Meals on Wheels for older people. Age might actually highly correlate with social risk factors, as well.”
NQF plans to continue its work to define what is truly a clinical or social risk factor, acknowledging that some of those may be one in the same. This will require a reexamination of clinical risk, the way the medical industry understands clinical risk, and how these factors play into payment models.
In turn, it may point to a new set of industry priorities, Agrawal said.
Again, there is no easy answer to these questions, and NQF itself hasn’t answered them. But as it continues its exploration of SDOH, Agrawal hopes to better understand the role the medical community needs to play in addressing social factors.
“There has been a growing realization over several years that socioeconomic factors matter in terms of determining healthcare outcomes,” Agrawal concluded. “We have so many analyses and papers proving the impact of the social determinants, so it’s a really big issue in which payers, providers, organizations like NQF, we all have a role to play.”
Date: May 30, 2019
Source: Patient Engagement HIT