No Clear Answers to Address Patient Social Risk Factors

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By Jennifer Van Winkle 
Clinical Product Manager, Change Healthcare
Patient Social Risk Factors

Despite the best efforts of your clinical staff, there are certain patients that home health just can’t help because of social risk factors. It’s not your fault or your staff’s fault—and it isn’t the patient’s fault, either.

The patient may have no way to get to doctor’s appointment or enough co-pay money to buy that critical prescription. Even though she answers the questions correctly about medications or therapies, the patient doesn’t have enough health literacy to really comprehend what’s required. In these cases, a hospital admission or readmission is likely, which can be a black mark against the hospital and one against the home health organization, too.

The effect of these and other social risk factors on health behaviors hasn’t been studied extensively. However, providers in some Medicare programs get hit with reimbursement penalties for poor outcomes that may be out of their control.

In response to reporting questions and provisions of Improving Medicare Post-Acute Care Transformation (IMPACT) Act, The National Academies of Sciences, Engineering, and Medicine has been working on a series of five reports that study social risk factors in Medicare payment programs mandated by the IMPACT Act.

The third report, “Accounting for Social Risk Factors in Medicare Payment: Criteria, Factors, and Methods,” outlines steps the Centers for Medicare & Medicaid Services (CMS) can take to incorporate social risk factors, but the report notes there are no clear answers.

According to the report, the committee’s goals in accounting for social risk factors in Medicare payment programs are:

  1. Reducing disparities in access, quality and outcomes
  2. Quality improvement and efficient care delivery for all patients
  3. Fair and accurate public reporting
  4. Compensating providers fairly

“To achieve these goals, accounting for social risk factors should neither mask low-quality care or health disparities nor reward poor performance,” the report states. “Additionally, inclusion of social risk factors in quality measurement and payment should not disincentivize providers from finding strategies to overcome the influence of social risk factors on health care outcomes.”

According to the report, a common complaint from some providers has been the cherry-picking of healthier and wealthier patients in more prosperous communities, leaving those with greater health needs and less family and community support with charity-care providers. If the reimbursement is similar for patients in widely differing circumstances, the charity-care provider has the greater burden.

The study concludes that several measurable social risk factors could be included in Medicare programs in the short term. Those include:

  • Income, education and dual eligibility
  • Race, ethnicity, language and nativity
  • Marital/partnership status and living alone
  • Neighborhood deprivation, urbanicity and housing

Longer term factors that could be included are:

  • Wealth,
  • Acculturation
  • Gender identity and sexual orientation
  • Emotional and instrumental social support
  • Environmental measures of residential and community context

This report complements a recent Harvard Medical School study that concluded that nearly one-half of all 30-day readmissions could be attributed to factors outside those identified by CMS. According to the study, the most important factors included a patient’s socioeconomic status, functional status, education level and self-reported health status.

As reimbursements increasingly are being tied to outcomes in value-based payment models, the idea that not every patient is the same takes on new resonance.

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