The move to pay for the “value” of health services has brought the issue of social determinants of health (SDH) and the value of social services to the discussion. On a macro-level, while the U.S. spends far more per capita than other industrialized countries on health care, spending on social services is far less (see Health Care Spending Vs. Social Service Spending and The U.S. Social Services Market: Almost 50 Million Receive Social Support & Over $318 Billion In Spending). And, the resulting health outcomes are mediocre at best (see Health And Social Services Expenditures: Associations With Health Outcomes).
At the delivery system level, health care services and social services are quite disconnected. But, there is a body of emerging data to show that social factors do have a significant influence health care costs (see Social Risk & The ‘Value’ Of Health Care and Social Determinants, Health Care Outcomes, & Health Care Costs – A Look At The Numbers). At the same time, funding for social services is on the decline-and may further decline as a result of the recent federal tax bill. As a result, I’ve been having some interesting discussions with colleagues who are executives of social service organizations, about how to move to “value-based” reimbursement for social services. There is a growing number of pay-for-success initiatives in social services-and we’ve covered a number of these (see Social Impact Bonds – Moving From Experimental To Scale and Social Impact Bonds: Small Model, Big Implications For Value-Based Reimbursement). But those initiatives are still not linked to the larger health care system-and it is that linkage that could provide a sustainable stream of funding for social services.
But to do this, better standardized models and methods to quantify, on a more granular level, the impact of social factors and social support services on health care costs are needed. There are a number of conceptual frameworks that have been released to help organizations recognize and categorize different SDH, including one in 2015 from RAND (see Understanding the Upstream Social Determinants of Health); and another by the National Quality Forum (NQF) in 2014 (see Should Provider Performance Measures Be Risk-Adjusted For Sociodemographic Factors? and Risk Adjusting Measures for Socioeconomic Status). At that time, NQF concluded that “not adjusting for patients’ sociodemographic factors might actually harm patients, exacerbate disparities in care, and produce misleading performance scores for a variety of providers-which means that no one has accurate information to use for comparison.
A recent report from Deloitte, Addressing Social Determinants Of Health In Hospitals, found that while screening for SDH and social needs was inconsistent, it was happening. Their analysis found that:
- Most hospitals screen for social needs (88%); but this is often “occasional or ad-hoc” (26%)
- Hospitals are primarily screening their inpatient (90%) and high-utilizer populations (83%)
- Fewer hospitals (69%) are screening more broadly in their communities
- 40 percent of hospitals report having no current capabilities to measure the outcomes of their activities
And, there are eight current VBP programs in Medicare that risk adjust for social risk factors: Hospital Readmission Reduction Program; Hospital-Acquired Condition (HAC) Payment Reduction; Hospital Value-Based Purchasing; Medicare Shared Savings Program; Physician Value-Based Modifier; End-Stage Renal Disease Quality Incentive Program; Medicare Advantage (MA)(Part C); Medicare Part D; Skilled Nursing Facility Value-Based Purchasing; and Home Health Value-based Purchasing (see Accounting For Social Risk Factors In Medicare Payment: Identifying Social Risk Factors (2016)).
Medicare Value-Based Payment Programs Risk-Adjusted For Social Determinants Of Health
Incentive Design, Including Maximum Adjustment
|Hospital Readmission Reduction Program||-1% 2013
|Demographic characteristics, clinical comorbidities, patient frailty|
|Hospital-Acquired Condition (HAC) Payment Reduction||Top 25% worst performing hospitals receive a reduction of 1% of all discharge payments||Age, sex, comorbidities, complications|
|Hospital Value-Based Purchasing||1% in 2013, increasing 0.25% each year until 2%||Demographics and comorbidities; education, self-rated health, response percentile, primary language other than English, and age|
|Medicare Shared Savings Program||ACO expenditures above/below benchmarks||Demographics; and disease severity|
|Physician Value-Based Modifier||Fixed negative adjustment of -1% in 2015 and
-2% in 2016
|Age, sex, education, general health status, mental health status, Medicaid status, low-income subsidy, Asian language, and clinical comorbidities|
|End-Stage Renal Disease Quality Incentive Program||-2%||Age, dialysis onset, body surface, body mass, comorbidities, overall health; overall mental health; heart disease; deaf or serious difficulty hearing; blind or serious difficulty seeing; geographic factors, and wage index|
|Medicare Advantage (MA)(Part C)||Bonus payments or rebates are a fixed
percentage (50, 65, or 70% based on Star Quality rating)
|Age, sex, clinical comorbidities, Medicaid status, disabled status, and working aged status|
|Medicare Part D||20% of the costs that are higher than expected||Age, education, general health status, mental health|
|Skilled Nursing Facility Value-Based Purchasing||-2% if facilities do not report quality data on three domains||NA|
|Home Health Value-based Purchasing||Incremental increase in maximum penalties or rewards of 5% in 2018, 6% in 2020, 8% in 2021||NA|
These are initial steps toward quantifying the risk of SDH-and ultimately attaching a value to social support services to address them. In the meantime, health plans and provider organizations in financing arrangements with financial risk are funding selected social support services on an ad hoc basis (see Assessing (& Addressing) Consumers’ Social Support Needs).
If you’re an executive of an organization providing a social service and want to move your proposals and contracting approach toward value-based reimbursement, take a look at the two earlier articles by my colleague, Howard Shiffman-Pay-For-Success Takes A Huge Leap Forward In Children’s Services and Pay-For-Success Takes Aim At Child Services.
For more on considering all aspects of a consumer’s health and social support needs, join Misty Tu, M.D., Psychiatrist, Addiction Medicine Services, Allina Health Systems on February 16 for her session, “Building Successful Value-Based Partnerships: How To Align Financial & Clinical Performance Goals” at The 2018 OPEN MINDS Performance Management Institute.