The Centers for Medicare & Medicaid Services (CMS) recognize that health care spending rises as a percent of gross domestic product (GDP) yearly while also underperforming on quality and equity. Recently government organizations like CMS and organizations like National Committee for Quality Assurance (NCQA) have ramped up initiatives to address social determinants of health (SDOH), or those factors that affect a person’s health outside of direct health care. They believe that addressing SDOH is the key to better health outcomes and lower spending, and a 2022 report published by HHS’ Office of Health Policy summarizes promising research indicating that interventions addressing risk factors such as housing, food and nutrition favorably impact health outcomes and costs. In this article we will review current and emerging initiatives including new and proposed SDOH quality measures and activities linked to plan and provider payments and incentives, discuss barriers to success, and propose win-win solutions for pharmaceutical companies to advance these initiatives.
Government and Other Initiatives
In 2021 PRECISIONvalue surveyed health plans, health systems, PBMs and ACOs (N=30; representing ~100 M Lives) on their organizations’ initiatives around social determinants of health (SDOH). The top 3 ways that respondents measured the success of their organizations’ SDOH initiatives were improvements on clinical outcomes (29.3%), quality measures (26.8%), and reductions in healthcare costs (25.6%). Further, 90% of the organizations responded that addressing SDOH was moderately to very important to the attainment of desired reductions in admissions and readmissions, ED visits, and 30-day mortality rates post hospitalization.
Key entities within the quality measurement and accreditation field are also recognizing that advancing equity is essential to improving health care quality and clinical outcomes, and are proposing quality measures aimed at SDOH processes or outcomes and instituting health equity activities within their current or proposed quality programs. Performance on many of these SDOH and Health Equity measures and activities will be publicly reported and linked to performance payments within value-based reimbursement programs. These steps will accelerate actions by plans and providers to address SDOH and health disparities. The following are a few examples of emerging or current metrics or activities.
The long-anticipated proposed model to follow the Oncology Care Model, The Enhancing Oncology Model (EOM), has recently been announced by CMMI. With a special emphasis on Health Equity, participants will be expected to develop a Health Equity Plan as a continuous quality improvement (CQI) requirement. Additional new, proposed activities will include the gradual implementation of electronically submitted patient reported outcomes (PROs) and screening EOM beneficiaries for social needs using a health-related social needs screening tool, with the expectation that beneficiaries will be screened for, at a minimum, three health-related social needs (HRSN) domains: transportation, food insecurity and housing instability.
CMS’s Quality Payment Program has designated several improvement activities to achieve health equity. Participant clinicians may receive payment for successful completion of the program. Examples of activities include: “Create and implement an Anti-Racism Plan” and “Implement Food Insecurity and Nutrition Risk Identification Treatment Protocols.” These initiatives promote development of tools and use of resources to address community needs.
CMS is also encouraging use of Z codes to document SDOH data (e.g., housing, food insecurity, transportation) and suggests a 5-step process for health care administrators, care teams, and coding experts for the collection and use of SDOH data to improve quality of care. Additionally, CMS is proposing advance shared savings payments for Medicare beneficiaries’ social needs and is hoping to support providers in rural and underserved areas to become part of Accountable Care Organizations.
Finally, the 2023 Medicare Advantage and Part D Advance Notice issued by CMS also requested public comment on their plans to develop a Health Equity Index (HEI) to enhance the Part C and D Star Ratings program, summarizing measure-level performance by social risk factors into a single score, potentially linked to a contract’s Star Rating and performance incentives. The development of a measure to assess whether plans are screening beneficiaries for SDOH such as food, housing, and transportation is also under consideration for inclusion within the Star Ratings. While CMS has noted that these changes would have to be adopted through the rule-making process, they are nevertheless signaling an intent to potentially integrate an HEI and an SDOH screening measure in the future and link them with a plan’s Star Ratings and performance incentives.
Outside of CMS, NCQA has sought comments on proposed new or modified Health Effectiveness Data and Information Set (HEDIS) measures around screening and data gathering. NCQA has proposed a new social needs screening quality measure to determine the percent of members being screened for food, housing and transportation insecurity and the percent who screened positive and received an intervention. Furthermore, NCQA is proposing expanding race and ethnicity stratifications for those measures that require it to improve transparency.
Significant Gaps Remain
While initiatives to address SDOH and improve health equity are necessary steps to improve overall health outcomes, we still have a long way to go in terms of actual improvements. While a health care provider may make a referral to community or government resources, that does not mean the patient will have access to needed housing or healthy food. For example, the National Low Income Housing Coalition reports that the United States has a shortage of 7 million affordable and available rental homes. The states with the greatest shortage are California, Oregon, Nevada, Arizona, Colorado, Texas, and Florida. Cities like Portland and Austin have increasing difficulty in providing effective support for individuals experiencing homelessness. Another area is food insecurity. With inflation after the pandemic, food banks have had more difficulty filling their shelves. For some patients, particularly Medicare beneficiaries, financial and transportation barriers limit access to health care and medications. Initiatives like Healthy People 2030 have evidence-based models that health system and payers can leverage at the local level to address these key areas impacting health. However, to drive uptake of these models, we will need more measures that go beyond screening and referral to move to definite outcome metrics that reflect a decline in homelessness and improved nutrition. This will require closing the loop on referrals and investment in infrastructure and supply chain management.
Pharma Driven Solutions
Pharmaceutical companies have national reach as well as local footprints that can be leveraged to support payers, providers, and states as they tackle the complicated issues around health equity. In addition, supporting access to treatments, housing, and nutrition, and reducing financial toxicity can potentially improve health outcomes and reduce healthcare costs. Given the low trust in pharmaceutical companies permeating the U.S., pharma may benefit from developing initiatives that generate good will.
1. Develop digital training tools to support SDOH screening, data collection, and identification of available resources.
2. Support multistakeholder collaboratives to build resources, develop sustainable models, and expand capacity.
3. Communicate successful results and lessons learned through roundtables, white papers, and patient journey roadmaps describing evolving solutions to close health disparity gaps, which will in turn generate further investment.
Some pharmaceutical manufacturers are emerging as health equity leaders, but comprehensive achievement in closing health equity gaps will require the entire industry. Engaging in efforts to address SDOH is not a one-way street wherein manufacturers spend money without a return on investment. Improvements in risk factors like inadequate housing, transportation, and nutrition will lead to better access to health care, increased use of innovative therapies, and improved response to pharmaceuticals. This can be a win-win for everyone.