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