By Priya Radhakrishnan, MD, FACP, Chief Academic Officer and VP Health Equity, HonorHealth
Health and health care inequities: systematic, measurable, and avoidable differences in health-related outcomes between populations are increasing in the United States. Access to healthy food, reliable transportation, safe shelter, and quality education are a few of the social and economic forces, the social determinants of health (SDOH) that explain a significant proportion of these gaps in health and health care. The Centers for Medicare and Medicaid Services (CMS) and Center for Medicare and Medicaid Innovation (CMMI) have funded the Accountable Health Communities Model to address the gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. CMS has rolled out a Health-related Social Needs Screening Tool (HRSN) with five domains (Housing instability, Food insecurity, Transportation problems, Utility help needs and Interpersonal safety) and eight subdomains (Financial strain, Employment, Family and community support, Education, Physical activity, Substance use, Mental health, and Disabilities).
The Business Case for Addressing Social Determinants of Health
Increasingly payors have moved towards risk-adjusted models, including capitated, global, and bundled payments, shared savings arrangements, and penalties for hospital readmissions that give health systems and practices economic incentives to incorporate social interventions into their approach to care. SDOH have a critical impact on key pay for performance indicators such as Hospital-Acquired Conditions, Readmissions, Value-based Purchasing programs and star ratings. Integrated Hospital systems that include an insurance arm have the highest opportunity for RoI. Value-based contracts with Medicaid and Advantage plans through ACOs and hospital performance indicators are other important areas which have the potential for high returns for systems that do not have a payor as part of their integrated network. The latter requires precision in funding areas that have the highest impact and alignment with the Community Health Needs Assessments (CHNA), an IRS requirement for not-for-profit hospitals or charitable mission-based community investments for other systems.
Opportunities for Developing a Digital Strategy to address SDOH
SDOH health initiatives are often missing from the health system’s digital transformation strategy largely because these are mission-based, non-revenue generators and require significant investment. Traditionally, mission-based programming is often siloed and not integrated within the health system’s initiatives.
EHR vendors have been remarkably slow in including SDOH assessment as part of the medical record. In addition, the SDOH data is not easily accessible to physicians and other clinicians such as case managers and care coordinators.
Mechanisms to integrate Z codes, a subset of ICD-10-CM codes are used as reason codes to capture “factors that influence health status and contact with health services”. While Z-codes have been traditionally used for research in the past, using the EMRs, to capture SDOH for research and driving policy, their use has been steadily increasing, largely due to the push by CMS and state Medicaid programs. Z codes are currently not part of the standard ICD10 compendium workflows. There are significant investments that need to be made by health systems to develop workflows and training of the workforce to integrate Z codes within.
In Arizona, the state Medicaid program is working with the state HIE to begin data transfer for SDOH. Several states are using the 211 database and vendors who have digitized the database to connect EHRs with community-based organizations. The reporting of Z codes has been very minimal. According to a study in 2017, 33.7 million total Medicare FFS beneficiaries in 2017, approximately 1.4% had claims with Z codes.
Medicaid programs in several states are working with CBOs through direct contracting. The uptake has been slow, largely because of constraints experienced by CBOs.
The processes for querying patients for SDOH and subsequently capturing the Z codes and documentation of services are cumbersome and about a decade old in terms of usability despite the current use of patient-generated data as chief complaints, review of systems or goals of care is becoming increasingly prevalent. This is particularly important because getting accurate answers for SDOH questions is more likely to occur if the respondents have some degree of control through questionnaires that they can answer compared to being asked the questions. Currently, digital front door innovations are largely targeted to build revenue than address SDOH and vulnerable populations.
Another fact that impedes the collection of accurate data is the lack of digitization for other languages. While the big EHRs have limited Spanish portals, few have robust non-English patient portals as part of their base subscription services, leading to a significant widening of the digital gap, especially for critical access hospitals that serve underserved populations. In addition, there is a significant limitation of content availability for non-English speakers. This is especially the case for the working poor, who often have more than one job and have limited access to care due to long working hours.
The widening gap between programs offered by integrated health systems which have health care plans targeted to the vulnerable populations; especially Medicare Advantage and Medicaid plans will continue to widen the divide since the reimbursement for services for complex care coordination and SDOH are supported by the value-based contracts. There is a significant opportunity for CMS to address this issue and “level the playing field”.
An area of increased growth is the proliferation of platforms that connect SDOH resources provided by o community-based organizations (CBOs) to health systems via curating the 211 resources (211 is a free information and referral service that connects people to health and human services in their community). States have invested in platforms that connect CBOs to Medicaid and health care systems via a closed-loop referral management process. This is an important step in connecting health care delivery systems to agencies that provide services. There is considerable work that needs to be done to help the CBOs adapt to using technology. Medicaid programs in several states are working with CBOs through direct contracting. The uptake has been slow, largely because of constraints experienced by CBOs.
The Path Ahead
The importance of SDOH on health care outcomes is undeniable with all the stakeholders working diligently on connecting the dots. It is important to remember the lessons learnt from the Meaningful Use journey – to focus on the patient and ensure that the burnout experienced by clinicians is not amplified due to lack of usability and lack of integration. Accessibility and Usability must be key areas of focus for all who invest considerable energy in solving major societal problems that directly impact health care outcomes.