Social Determinants of Health, Alternative Payment Models

AAFP Unveils Principles for Fair Measurement, Payment in APMs

May 18, 2018 04:02 pm Sheri Porter

Identifying and addressing the social determinants of health (SDOH) for each and every patient is becoming increasing important as physicians provide the best possible care in today's complicated health care system. Furthermore, these social determinants have ramifications when it comes to paying physicians through alternative payment models (APMs).

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That's why the AAFP has taken a positive step in laying out five principles in a new document titled "Advancing Health Equity: Principles to Address the Social Determinants of Health in Alternative Payment Models."

The AAFP explains the rationale behind the principles on the opening page:

"As more AAFP members participate in APMs, key issues for the AAFP include data on

  • the role of social risk factors in health outcomes,
  • the impact of such data on assessing physician performance, and
  • policy opportunities to improve payment and measures methodologies.

"These principles ensure that SDOH are appropriately accounted for in the payment and measurement design of APMs so that practices have adequate support to improve quality and outcomes for all patients, eliminate health disparities, and reduce costs for the health care system."  

Story Highlights
  • The AAFP has unveiled five principles related to how social determinants of health must be accounted for in alternative payment models.
  • The document makes clear that practices must have adequate support if they are to improve quality and outcomes for patients, eliminate health disparities and reduce costs for the health care system.
  • At a minimum, social factors that should be included are poverty, unemployment, household provider status, high-need age groups, transportation, crowding, uninsured status and race.

The Five Principles

The AAFP prefaced its introduction of the principles by pointing out that even as value-based payment programs require physicians to assess and address social determinants, "these models do not adjust or account for how these factors affect outcomes and performance."

The Academy also pointed out that in the past couple of years, the federal government has begun to look at the connections between social risk factors and physician performance in value-based payment programs as a way of aligning payments with the goals of these programs.

In addition, CMS is exploring how to account for social risk factors and reduce health disparities in its quality measurement programs.

Thus, the AAFP's efforts are both timely and on target with the principles briefly described below.

Principle one states that APMs should support family physicians' efforts to identify and address social determinants that are known to impact patients' health outcomes.

Furthermore, because social determinants of health are multifactorial -- and are linked to risks for various illnesses, life expectancy and lifetime morbidity -- risk-adjusted payment methodologies should include multiple evidence-based variables.

"Risk-adjustment methodologies should allocate more resources to those most disadvantaged by SDOH," concludes the first principle.

Principle two says that the inclusion of variables representing SDOH in APMs should be founded on evidence-based research.

"Practices should use additional risk-adjusted payments that account for SDOH to address health disparities in their patient population by supporting increased access, expanded population-based services, referrals and comprehensive care."

This principle notes that, at a minimum, social factors that should be included in measurement are poverty, unemployment, household provider status, high-need age groups -- defined as 17 years of age or younger, and 65 or older -- transportation, crowding, uninsured status and race.

It also discusses risk-adjustment models in Minnesota and Massachusetts that show measurement of social determinants is possible.

Furthermore, the National Academy of Medicine "produced a series of consensus-based reports on the issue, concluding that taking SDOH into account during quality measurement and payment design could improve quality, reduce costs, and address a range of health disparities."

Principle three states that health IT (HIT) platforms can facilitate the collection of SDOH data from medical records and other sources, and that doing so will support improved clinical decision-making, care coordination, quality measurement and population health management.

"When leveraged correctly, EHRs (electronic health records) can improve the integration of SDOH into clinical systems," says the AAFP.

Principle four offers that to minimize the administrative burden, SDOH data should be collected via existing mechanisms.

"Payers and HIT vendors are encouraged to use a consistent definition of SDOH and harmonize the variables and measures used to represent SDOH in risk-adjustment methodologies. Payers should be transparent in their incorporation of SDOH in their risk-adjustment methodologies and update them regularly or when new evidence is developed," says the principle.

Principle five says, "To ensure APMs improve access, quality and health equity, practices should receive appropriate resources and support to identify, monitor and assess SDOH."

Among other points, this principle describes the kind of support practices could be afforded, such as connecting with EHR vendors who can identify, monitor and assess social determinants; accessing relevant data sources outside the practice; collaborating with peers; receiving technical assistance; and utilizing feedback reports and coaching.

"By providing appropriate resources and support, APMs can help physicians and medical homes learn best practices and use data-driven approaches to meet the needs of their patient population," says this principle.

Family Physician Perspective

The project won the full support of Tamaan Osbourne-Roberts, M.D., of Denver, who serves on the AAFP's Commission on Quality and Practice and reviewed the principles before they were published online.

Osbourne-Roberts was well suited for the task given his position as chief medical officer at the Center for Improving Value in Health Care in Denver and his clinical experience serving low-income patients in a nine-clinic federally qualified health center.

He told AAFP News that physicians address patients' health with a variety of tools, and the use of data is one. However, he said, "if we don't think specifically and creatively about how to ensure that the data is inclusive and addresses social determinants of health, there are going to be gaps in using the data to maintain and improve people's health."

Osbourne-Roberts said the principles provide guidelines for how to create a health data infrastructure that will be both usable for family physicians at the practice level and benefit their patients.

"This is really a truly critical effort, because for many, many years the structure of what we do as physicians has not explicitly included concerns around health equity," said Osbourne-Roberts.

"Including these up front, at a time when the health data infrastructure is in its infancy, ensures that concerns of equity and the inclusion of social determinants of health are built into the system in a way that is innate, and not as an 'add-on' later.

"The value of that is hard to overstate," he said.

Related AAFP News Coverage
AAFP Takes Leadership Role With Launch of Center for Diversity, Health Equity
Initiative Will Use Evidence-based Approach to Address Social Determinants

(3/31/2017)

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