On Sept. 12, a headline in POLITICO asked a question with significant implications for the future of the health care system. “Should Medicare pay for toothpaste and shoes?” As the article details, there is growing evidence that approaching health problems and costs by identifying upstream influences, rather than in the clinical environment, can improve lives and outcomes.
The idea isn’t particularly new. For some time, experts have been stressing that social determinants of health play an important role in health status and health outcomes. MHA has helped inform this discussion through analysis of hospital super-utilizers, research on readmissions, adverse childhood experiences and ZIP code-level identification of risk. However, on a patient level, data to identify and build tailored plans to address SDOH has lagged.
Several weeks ago, HIDI team member Mat Reidhead mentioned to me that he had identified some very interesting data points related to SDOH. He shared that hospitals were broadening their use of the ICD-10 codes to identify patients’ SDOH, and that the findings could have implications for future performance-based payment risk adjustment systems, and community and population health management. I encouraged him to put together a paper. The policy brief was released Tuesday.
There was a telling, and perhaps chilling, sentence on the first page of the report. “The criteria used to identify SDOH include factors that have a defined association with health, exist before the delivery of care, are not determined by the quality of care received, and are not readily modifiable by health care providers.” In an era of growing value-based reimbursement, how can clinicians identify, understand and mitigate the influence of SDOH on patient outcomes?
As this week’s report indicates, better coding of SDOH can be part of the answer. Compared to all hospital patients, individuals diagnosed with social complexity in Missouri have significantly higher rates of hospital utilization and social, behavioral and clinical risk factors. Of the 140,417 inpatient, outpatient and ED claims for 78,800 individual Missouri residents that included ICD-10 SDOH codes, the most common code was for homelessness. Homelessness was coded in 34,171 claims and accounted for 19.1 percent of all SDOH codes detected. Among patients diagnosed with housing problems — which is primarily indicative of homelessness — the rate of super-utilization was 21.7 percent. This was 26 times the same rate in the non-SDOH patient population.
Better coding, more broadly adopted, could support better risk-adjustment policies reflective of the influence of SDOH. Unfortunately, since the transition to ICD-10 in October 2015, the standardized use of these codes appears to be somewhere in the middle on a scale of nascent-to-nonexistent. This is understandable. The incentives are long-term, while the problem is short-term. And, there’s no guarantee that policy will follow the emerging evidence.
My friend and former MedPAC colleague, David Nerenz, who researches the effects of social complexity at Henry Ford in Detroit, and co-chaired the expert panel on socioeconomic risk at the National Quality Forum, sent his thoughts on the new research. He said, “Hospitals and other health care providers are being asked to address social determinants of health, but there are generally no funding mechanisms available to support that work. If the ICD-10 codes on social determinants were linked to payment for activities addressing those social determinants, then there would be a strong positive incentive for the accurate use of those codes.”
Where deeper coding on SDOH is present, there’s strong evidence that the determinants are influencing outcomes. It’s hard not to think that some of the extreme outliers — hospital super-utilizers with housing or homelessness issues — aren’t solving part of their challenge for shelter in a hospital ED or inpatient bed. The influence of other SDOH may eventually become clear as deeper coding allow better identification of these externalities.
Whether Medicare or other payers pay for shoes or toothpaste to reduce utilization is an important policy question. It appears that progress is being made in connecting SDOH and clinical costs. The body of research connecting SDOH to care quality is growing, benchmarking is evolving — including the use of dual eligibility status as a marker in hospital comparatives — and Medicare Advantage plans have new authority to provide nonclinical “supplemental benefits” to reduce utilization.
All of these developments are promising. And, better coding could inform the need for future innovation.
This week, Federal Reserve Chair Jerome Powell said, “It’s no secret: It’s been true for a long time that with our uniquely expensive health care delivery system and the aging of our population, we’ve been on an unsustainable fiscal path for a long time.”
Shoes and toothpaste are a lot less costly for the system than inpatient care. However, health care organizations still are evolving to meet the challenges of a system that asks institutions and caregivers to move from the clinical environment to patients’ homes and communities. We need not only the data that can help assess risk, but the hospital- and community-based assets — social workers, community health workers and clinics — that can reach deeper into the health challenges of patients and determine whether social or clinical care can improve outcomes.
Paying for coding makes sense. Just like paying for shoes can make sense.
Bending the cost curve will require a whole new paradigm.
Let me know what you think.
Herb B. Kuhn
MHA President and CEO
In This Issue
Medicare Advantage Premiums Decrease For 2019
MHA Releases Flu Monitoring Summary
September 24, 2018
HHS Expands Access To Buprenorphine Via Telemedicine
Dept. Of Revenue To Correct State Income Tax Withholding Tables
This Week Is Falls Prevention Awareness Week
Your Vote Matters
September 25, 2018
MHA Releases Policy Brief On Social Determinants Of Health
Legislative Committee Takes No Action On Medicaid Outpatient Payment Regulation
MO HealthNet Revises Claim Form For Therapies For Severely Traumatized Children
MHD Tightens Claims Requirements For Prescribing Providers
MHA Conducts Weekly Flu Monitoring Beginning This Thursday
Improvement Sprints “UP” The Ante In Missouri Hospitals
Fellowship Application Period Open
September 26, 2018
Congressional Negotiators Develop Compromise Opioid Legislation
Anthem Exits Individual Marketplace Coverage In 14 Counties
HIDI Releases 2017 Annual Survey Trends Report
Trajectories — Integrating Evidence-Based OUD Treatment: A Medication First Model
Tomorrow, CDC Hosts Webinar On Pediatric Influenza Recommendations
September 27, 2018
Congress Posts New Information About Pending Opioid Legislation
MLN Connects Provider eNews Available
Devocelle Announces Retirement From Olathe Health
Peterson Announces Retirement From Stormont Vail Health
Fletcher Announces Resignation From Ellett Memorial Hospital