Devil is in the de­tails for de­ter­min­ing how to ap­ply so­cial de­ter­mi­nants of health

Modern Healthcare - - COMMENT - By Dr. David Levine

The 21st Cen­tury Cures Act, now law, is best known for fund­ing prom­i­nent med­i­cal re­search ini­tia­tives and for ac­cel­er­at­ing the re­view of drugs and de­vices at the U.S. Food and Drug Ad­min­is­tra­tion.

But for hos­pi­tals, par­tic­u­larly safety net fa­cil­i­ties car­ing for our na­tion’s most un­der­served com­mu­ni­ties, the law’s pas­sage is an equally im­por­tant vic­tory.

For years, these hos­pi­tals have been un­fairly pe­nal­ized by a pro­gram de­vel­oped by the CMS to curb hos­pi­tal read­mis­sions rates, known as the Hos­pi­tal Read­mis­sions Re­duc­tion Pro­gram, or HRRP. More than 75% of the na­tion’s 3,400-plus hos­pi­tals will face a penalty un­der HRRP for fis­cal 2016, with to­tal penal­ties ex­pected to ex­ceed $500 mil­lion.

The in­tent of the CMS pro­gram is laud­able. But in prac­tice, HRRP pe­nal­izes hos­pi­tals for the com­mu­ni­ties they serve, not for the qual­ity of care that’s de­liv­ered. That is be­cause im­por­tant pop­u­la­tion char­ac­ter­is­tics such as so­cio-eco­nomic sta­tus, or SES, have not been fac­tored into how the CMS eval­u­ates hos­pi­tal per­for­mance.

In gen­eral, we know that low-SES com­mu­ni­ties ex­pe­ri­ence more acute health events due to a lack of ad­e­quate out­pa­tient care man­age­ment. Con­tribut­ing fac­tors in­clude less ac­cess to pri­mary care, lack of money for med­i­ca­tions and a lack of healthy food op­tions—among other is­sues that are of­ten out­side a hos­pi­tal’s con­trol.

The im­pact that SES has on pa­tient out­comes has been con­firmed in med­i­cal lit­er­a­ture, as well as in our own re­search at Vizient. Based on a re­view of pa­tient en­counter data submitted by nearly 300 par­tic­i­pat­ing aca­demic med­i­cal cen­ters and com­mu­nity hos­pi­tals, we found no­table dif­fer­ences in pa­tient out­comes based on SES. Low-SES heart fail­ure pa­tients, for ex­am­ple, have a 12% higher read­mis­sion rate than for non-low SES pa­tients. And, for be­hav­ioral health, read­mis­sions are 11% higher among low-SES pa­tients.

So how should we mea­sure so­cial de­ter­mi­nants of health?

With the pas­sage of the Cures Act, the CMS is now un­der a man­date to ad­dress SES as part of mea­sur­ing hos­pi­tal read­mis­sions. This is wel­come news for aca­demic med­i­cal cen­ters and other hos­pi­tals that serve our na­tion’s most vul­ner­a­ble pa­tients. Now the real work be­gins. The new law doesn’t in­clude spe­cific guid­ance on how so­cial de­ter­mi­nants of health should be mea­sured and mod­eled into qual­ity re­port­ing. De­ter­min­ing SES risk ad­just­ment for read­mis­sions will be a sig­nif­i­cant chal­lenge and re­mains the open, $500 mil­lion ques­tion for hos­pi­tals.

Of note, the Cures Act calls for cre­at­ing co­horts of hos­pi­tals that care for a sim­i­lar so­cio-eco­nomic mix of pa­tients—in this case, fo­cus­ing on pa­tients du­ally el­i­gi­ble for Medi­care and Med­i­caid. The in­tent is to com­pare hos­pi­tals with a large per­cent­age of low-SES pa­tients against other hos­pi­tals with a sim­i­lar pa­tient pro­file. There are a few chal­lenges with this ap­proach, in­clud­ing de­ter­min­ing what cut­offs will be used to de­ter­mine the penal­ties as­sessed to each co­hort.

Be­sides co­horts, the CMS should in­clude other de­mo­graphic fac­tors in de­ter­min­ing SES. Eval­u­at­ing ZIP codes served by a hos­pi­tal and re­fin­ing with cen­sus data and street ad­dresses would of­fer greater in­sights into SES. An­other proxy of SES is pen­e­tra­tion of school lunch vouch­ers.

Other fac­tors not cur­rently cap­tured by risk ad­just­ment but in­flu­enc­ing read­mis­sions and cor­re­lated with low SES in­clude health lit­er­acy, prox­im­ity of gro­cery stores with fresh fruit and veg­eta­bles and ac­cess to pub­lic trans­porta­tion.

No model is per­fect, how­ever. Even if a hos­pi­tal pro­vides proper dis­charge in­struc­tions, en­sures med­i­ca­tion avail­abil­ity and af­ter­care be­yond a seven-day win­dow, fac­tors out­side of a hos­pi­tal’s con­trol be­gin to have a much larger in­flu­ence over out­comes. Chang­ing the read­mis­sions mea­sure­ment pe­riod from 30 days to seven days would go a long way to level the play­ing field for hos­pi­tals and bet­ter re­flect qual­ity of care. The need for so­cio-eco­nomic ad­just­ment would also be min­i­mized.

As the CMS be­gins de­vel­op­ing for­mal guid­ance on ac­count­ing for SES, we look for­ward to work­ing with the agency to help steer this much­needed im­prove­ment to qual­ity mea­sure­ment.

In­ter­ested in sub­mit­ting a Guest Ex­pert op-ed? mod­ern­health­care.com/op-ed. View guide­lines at Send drafts to As­sis­tant Man­ag­ing Ed­i­tor David May dmay@mod­ern­health­care.com. at

Dr. David Levine is se­nior vice pres­i­dent of ad­vanced an­a­lyt­ics and in­for­mat­ics/ med­i­cal di­rec­tor at Vizient.

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