Every day, physicians encounter patients in their practices who show the toll of skipping meals to feed their children, or who cannot refrigerate their insulin because they have no electricity. They know that improving their patients’ health is achievable only by addressing these and other social drivers of health (SDOH), but are often limited in their ability to do that.
The Centers for Medicare and Medicaid Services (CMS) could change that by enacting the first-ever measures in a federal quality or payment program that offers incentives to physician practices and hospitals to engage their patients around these issues.
A recent survey of America’s physicians conducted by The Physicians Foundation found that 80% believe that “the country cannot improve health outcomes or reduce health care costs without addressing SDOH.”
Patients — and the physicians who care for them — bear the economic and psychological risk associated with unaddressed social drivers of health. The inability to address these drivers can lead to physician burnout, as well as penalize physicians caring for affected patients via lower scores on federal quality programs, like CMS’s Merit-based Incentive Payment System, which, in turn, negatively affects physician reimbursement.
Physicians themselves have identified the top three most important strategies to address these issues: asking patients about their social needs, like access to healthy food or safe housing; investing in the technological and human capacity to connect patients with the community resources they need; and investing to ensure there are adequate community resources to meet patients’ social needs. In particular, the majority of physicians surveyed (65%) cited the importance of public and private payers enacting quality measures that address social drivers of health to improve health outcomes and ensure high-quality, cost-efficient care.
Yet even with an ongoing pandemic that has painfully brought these issues to the fore, no measures of social drivers of health exist in any federal quality and payment programs, and these factors are still not accounted for in CMS’s “risk adjustment” calculations — how healthy (or sick) a patient is and, therefore, how much their physician should be paid to care for them.
The Physicians Foundation, whose directors are appointed by 21 state and county medical societies, responded to CMS’s annual invitation for new Medicare measures by putting forward the first two SDOH measures ever proposed. These focus on the percentage of patients who are asked about food insecurity, housing instability, inadequate transportation, interpersonal safety, and difficulties paying for electricity and other utilities; and the percentage of patients who are positive for each of these needs. Even though CMS has declared it a priority to “develop and implement measures that reflect social and economic determinants,” these two measures are the only ones related to social drivers of health and are the only patient-level equity measures in this review cycle.
To truly move the needle to improve health outcomes for vulnerable Americans and give physicians the quality measures they want and need, CMS must act now to incorporate these two measures. Last week, CMS took a crucial first step by proposing these measures for the Hospital Inpatient Quality Reporting Program, which sets rules for Medicare payments to hospitals. Next, it will consider the same measures for the Merit-based Incentive Payment System.
Many stakeholders have emphasized the particular importance of the percentage of patients who screen positive for social needs. The rate itself should not be rewarded or penalized, recognizing that it would be influenced by the community in which a practice exists and its patient population. Yet this measure is essential to make visible and address factors that contribute to health disparities and support improvement activities. In addition, this measure would enable CMS to account for patient-level social drivers of health in risk adjustment, providing a more complete picture of the impact of these factors on health care costs, outcomes and disparities.
Both measures are essential to fulfill CMS’s commitment to health equity — articulated in its recently released health equity strategy pillar and its vision for the Centers for Medicare and Medicaid Innovation and its associated health equity initiatives, all of which cite the importance of routinely and in standard ways “collecting self-reported demographic and social-needs data.”
Over time, these measures of social drivers of health can and will be improved with the benefit of the input of physicians and patients across the country and the data generated by these measures. Yet we also recognize that, given the profound challenges that Covid-19 has wreaked on patients, physicians, and the U.S. health care system at large — and the commitment to equity and the reduction in health disparities that CMS and health care institutions across the country have declared — that time is of the essence in enacting these historic measures of social drivers of health.
Michael Darrouzet is the chief executive officer of the Texas Medical Association. Jennifer Lawrence Hanscom is the chief executive officer of the Washington State Medical Association. Chip Baggett is the chief executive officer of the North Carolina Medical Society. All are board members of The Physicians Foundation, a nonprofit seeking to advance the work of practicing physicians and help them facilitate the delivery of high-quality health care to patients.