The AAFP recently responded to a request for information(aspe.hhs.gov) (RFI) from HHS that asked a series of questions about approaches for improving health care for Medicare beneficiaries with social risk factors.
The RFI was issued pursuant to research required by the Improving Medicare Post-Acute Care Transformation Act of 2014.
In the Nov. 14 letter(4 page PDF) to HHS Deputy Assistant Secretary John O'Brien, which was signed by AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan., the AAFP commented on four specific areas outlined by HHS.
The topics centered on
- identifying beneficiaries with social risk factors,
- describing approaches to address the needs of these beneficiaries,
- sharing evidence about the impact of these approaches on quality outcomes and the total cost of care, and
- separating and addressing beneficiaries' social and medical risks.
- The AAFP responded to an HHS request for information on how to improve health care for Medicare patients with social risk factors.
- The AAFP outlined its principles for incorporating social determinants of health (SDOH) into new payment models.
- The letter also highlighted strategies the AAFP has undertaken to integrate SDOH adjustments into the AAFP's proposed advanced primary care model.
In the RFI, HHS noted the growing recognition of the role social risk factors play in an individual's health and pointed out that the health care system "is increasingly moving toward higher levels of provider accountability for the quality, outcomes and costs of care."
The AAFP began its response by highlighting its leadership in the area of social determinants of health (SDOH) -- including its work to create a policy that defines SDOH as "the conditions under which people are born, grow, live, work and age."
"Our response to this RFI offers data and experiences from our members, outlines the AAFP's principles for incorporating SDOH into new payment models, and highlights strategies the AAFP has undertaken to integrate SDOH adjustments into the AAFP's advanced primary care model," said the letter.
The AAFP drew on members' responses to the Academy's 2017 SDOH survey.(514 KB PDF)
For instance, the AAFP told HHS that based on survey results,
- nearly 60 percent of family physician respondents already screen patients for SDOH and
- 52 percent follow up on identified SDOH needs by referring patients to community-based social services.
The Academy also offers family physicians use of the AAFP's nationwide Neighborhood Navigator referral network,(neighborhoodnavigator.auntbertha.com) which connects patients to food, housing and other SDOH resources based on individual needs.
On the question of whether evidence shows SDOH approaches used by the AAFP and others are making an impact on quality outcomes and cost of care, the letter noted that a systematic review of SDOH screenings in 2017 concluded that research evaluating their effectiveness has instead focused on process outcomes and feasibility.
"High-quality evidence does not yet suggest that these approaches have any effect on an individual's health outcomes, … health care cost, utilization or quality," said the AAFP.
However, the letter pointed out that the AAFP is working to develop tools to calculate a practice's return on investment related to SDOH. Such a calculation is impossible at this time because physician payment is usually based on individual health needs rather than overall impact on population health.
Regarding HHS' query about how to separate Medicare patients' social and medical risks, the AAFP said the two types of risk "are inherently connected."
The AAFP also took the opportunity the RFI presented to tell HHS that the Academy has developed principles to address SDOH in alternative payment models (APMs) and urged HHS "to consult and utilize" those principles to ensure that SDOH are accounted for "in the payment and measurement design of APMs."
The AAFP reminded HHS of the Academy's proposed Advanced Primary Care Alternative Payment Model (APC-APM) that would, if implemented, empower small and independent family medicine practices to make the move from fee-for-service payment to "population-based predictable revenue streams" that would be risk-adjusted, in part, based on SDOH and would "support comprehensive, longitudinal and high-quality primary care."
In addition, the letter highlighted potential use of the Social Deprivation Index (SDI)(www.graham-center.org) created by the Robert Graham Center for Policy Studies in Family Medicine & Primary Care as a tool to level the payment playing field.
The index includes variables of social deprivation and provides a single index at various geographic levels, including ZIP code.
"In the APC-APM model, attributed patients would be assigned an SDI based on the ZIP code of their home address, and a monthly payment adjustment would be made for attributed patients at or above the 85th percentile on the SDI.
"This is one example of how new payment models and approaches can begin to incorporate SDOH simply and efficiently," said the AAFP.
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