The Boston-based physician organization wants social drivers of health included in payment models for healthcare services.
The Physicians Foundation is pressing the Centers for Medicaid and Medicare Services (CMS) to adopt new measures for social drivers of health.
The Physicians Foundation has adopted the term social drivers of health rather than social determinants of health. As detailed in a Health Affairs article published last year, social drivers of health is a more precise term, which also does not strip people of "their agency to manage their own health and well-being—as though their struggles to access food or housing were pre-determined and thus unalterable."
In a recent interview, HealthLeaders spoke with Gary Price, MD, president of The Physicians Foundation, about his organization's work on social drivers of health. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary CMS measures for social drivers of health that The Physicians Foundation has proposed?
Gary Price: The Physicians Foundation recently released Improving America’s Health Care System: Recognize the Realities of Patients' Lives and Invest in Addressing Social Drivers of Health, which outlines four principles with 17 pragmatic steps that are needed to address social drivers of health (SDOH) that impact physicians and patients across the country. These actionable recommendations focus on how to address SDOH in how we pay for and deliver care to improve health, while reducing costs and easing administrative burdens on physicians. One key principle is the imperative to create new standards for SDOH quality, utilization, and outcome measurement.
Every year, CMS invites recommendations for new measures aligned with the agency's priorities, and the agency recently declared a priority to develop and implement measures that reflect social and economic drivers. Consistent with the recommendations we recently released, The Physicians Foundation submitted the first-ever SDOH CMS measure set to be included in federal payment programs:
- Percentage of beneficiaries 18 years old or older screened for food insecurity, housing instability, transportation problems, utility help needs, and interpersonal safety
- Percentage of beneficiaries 18 years old or older who screen positive for food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety
CMS has included these SDOH measures in its "measures under consideration" list for the Merit-based Incentive Payment System (MIPS) and the Hospital Inpatient Quality Reporting Program. Importantly, these measures—stratified by race and ethnicity—have been well-tested in over 600 clinical sites across the country through the CMS innovation center's Accountable Health Communities model.
HL: Why is adoption of the proposed CMS measures important?
Price: Despite the well-documented impact of SDOH on health outcomes and costs and their disproportionate impact on communities of color, there are still no drivers of health measures in any federal healthcare payment or quality programs. Reducing total cost of care and achieving health equity are only achievable by addressing SDOH. Yet, this is not how our system operates.
For example, under federal payment and quality frameworks, the healthcare system codes, screens, measures, and risk-adjusts for diabetes, but not for food insecurity—even though diabetics who are food insecure have worse health outcomes and cost on average $4,500 more per year than those with access to healthy food. A system that does not collect and act on food insecurity data cannot address rising healthcare costs or reduce racial disparities, especially given that Black Americans face the highest rates of both food insecurity and diabetes.
Likewise, SDOH lead to physician burnout and effectively penalize physicians for caring for affected patients via lower MIPS scores. A recent JAMA study, from The Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medicine found that SDOH were associated with 37.7% of variation in price-adjusted Medicare per beneficiary spending between counties in the highest and lowest quintiles of spending in 2017. Yet even with an ongoing pandemic that has painfully brought these issues to the forefront, SDOH are still not included in any geographic adjustment or cost benchmarks.
Physicians are held responsible for patients' health through quality measures and financial rewards or penalties that focus almost entirely on clinical care. As SDOH drive 70% of health outcomes and associated costs, we must create financial incentives and risk models to account for the realities of patients' lives.
HL: What are the primary goals for addressing SDOH at The Physicians Foundation?
Price: We aim to continue building broad-based understanding of the SDOH and their implications for patients and physicians. We have been pursuing this goal for more than a decade through research, education, and innovative grant making.
For example, The Physicians Foundation collaborated with Health Leads to develop and implement the first-ever system to help enable physicians to screen their patients for SDOH and automatically connect or refer them with the basic resources they need to be healthy.
The healthcare sector is increasingly recognizing that America cannot improve health outcomes or reduce healthcare costs without addressing SDOH, but greater action is required in four arenas:
1. Address SDOH in combatting COVID-19: The Physicians Foundation recognizes the imperative to incentivize and invest in addressing SDOH as a key facet of tackling the pandemic and its aftermath, for both physicians and their patients.
2. Integrate SDOH into payment policy: Federal and state policymakers and private insurance companies have increasingly held physicians responsible for patients' health through quality measures and financial rewards and penalties that focus almost entirely on clinical care.
3. Create new standards for SDOH quality, utilization, and outcome measurement: Develop standard measures to address and quantify the impact SDOH have on health outcomes, costs, and disparities; understand barriers to effective care; more accurately risk adjust payment models and establish cost benchmarks; and quantify latent financial risk in the healthcare system.
4. Make SDOH central to an innovation agenda: the Center for Medicare & Medicaid Innovation has field-tested addressing SDOH via its Accountable Health Communities model, which has screened about 1 million patients for social needs, and its Comprehensive Primary Care Plus model, in which 93% of practices are now screening for SDOH. A number of states have also integrated SDOH into care delivery. Building on this experience and data, CMS and states now have the opportunity to spur further action on these issues.
HL: What is the role of physicians in addressing SDOH?
In The Physicians Foundation's 2020 Survey of America's Physicians: COVID-19 and the Future of the Health Care System, 73% of physicians indicate that SDOH such as access to healthy food and safe housing will drive demand of healthcare services. Additionally, almost 90% of physicians said their patients had a serious health problem linked to poverty or other social conditions. It is critical that physician and patient voices remain central to the discourse and decision-making on health reform and SDOH. Individual physicians are closest to these issues and their perspectives are critical to improving patient outcomes.
HL: What are the prospects for the medical community addressing SDOH? How far have we come, and how much further do we need to go?
Price: As mentioned previously, The Physicians Foundation has been recognizing and acting on addressing SDOH for more than a decade, which was long before most stakeholders in the healthcare system. However, with a federal administration committed to operationalizing equity; a pandemic that has exacerbated rates of food insecurity, housing instability, and other SDOH, and the clinical disease burden linked to these factors; and the Medicare Trust Fund projected to be insolvent in five years; now is the moment our community can take major strides to have SDOH comorbidities be recognized and acted upon.
In addition to federal efforts, the medical community in each state needs to work collaboratively with their state legislature and department of health and human services to embed SDOH within financial incentives and quality measures.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
One key principle is the imperative to create new standards for social drivers of health (SDOH) quality, utilization, and outcome measurement.
As SDOH drive 70% of health outcomes and associated costs, financial incentives and risk models must be created to account for the realities of patients' lives.
Standard measures are critical to address and quantify the impact SDOH have on health outcomes, costs, and disparities.