Is it time to consider social determinants of health in Medicare payments?

Eta was a 76-year-old woman with a recent heart attack in and out of the hospital over the last several months. Her course had been complicated by social determinants of health, in that she lacked reliable transportation for necessary follow-up, had unstable housing, and her insurance did not cover valuable care from home health agencies. These obstacles made it difficult for her and her doctors to ensure that she recovered. As a geriatrics researcher and emergency physician, I have coordinated care for Medicare patients like Eta, to ensure they get the additional services they need. However, clinicians are often seemingly punished by reduced Medicare reimbursements when caring for these patients, thereby often creating a perverse disincentive to help this population most at need and potentially exacerbating health disparities.

Is it time for Medicare payments to take social determinants of health into account?

Medicare is increasingly shifting towards pay-for-performance programs and away from fee-for-service models where clinicians were reimbursed based on the volume of patients seen. Many factors have been shown to impact a clinician’s performance, with a landmark 2017 Report identifying that patient outcomes are affected significantly by social risk factors, including minority race or ethnic background, living alone or in a deprived neighborhood, and dual-eligible status (Medicare & Medicaid) as a marker for low income. Furthermore, access to safe environments and stores that sell fresh and healthy food significantly impact the patient outcomes that clinicians are judged on and reimbursed on in pay-for-performance programs.

Dually-enrolled beneficiaries have been shown to have poorer outcomes on numerous quality measures, including but not limited to cancer screening, diabetes control, communication from doctors, and hospital readmissions. These findings are a concern to policymakers, researchers, and clinical providers since Medicare beneficiaries particularly impacted by social determinants of health often cluster together in inner-city or rural communities with a small group of clinicians. Without accounting for certain social determinants of health, Medicare payment programs may devalue the quality of care provided by safety-net clinicians that disproportionately care for these populations.

This debate has only grown over the last few years, with more recent data showing continued negative quality measure performance and associated payments for clinicians caring for populations particularly impacted by social determinants of health.

In a recent analysis, almost 300,000 physicians were grouped by the proportion of their patients that had dual-eligible status, serving as a proxy for those impacted by social determinants of health. Physicians with the highest amount of socially disadvantaged patients had quality measure scores that were significantly lower than those taking care of a more socially affluent population. This difference directly results in reduced payments for clinicians caring for patients who often need care the most.

Additionally, the urgent need to address this topic is evidenced by the Social Determinants Accelerator Act, a bipartisan bill introduced in July 2019, that has stalled in the House Energy and Commerce Subcommittee on Health. Intended to help states and communities devise strategies to address at least one health and one social outcome for a targeted population, readdressing this issue within the U.S. Congress will provide additional resources to clinicians caring for those socially disadvantaged patients.

Opponents to accounting for social determinants of health frequently highlight two main arguments. First, Medicare has recognized patient medical and social complexity by providing clinicians modest bonuses. Despite this, CMS’s own analyses have suggested that these bonuses are unlikely to adequately compensate for quality measure and payment differences. Second, others argue that accounting for social determinants of health within quality measures may excuse physicians or small groups that deliver substandard care. A compromise approach has been suggested to adjust payments to clinicians, rather than quality measure scores, thereby holding clinicians to the same standard for all populations.

Two outcomes should be prioritized with these considerations taken into context. While CMS is working to develop a new value-based program, additional financial relief should be provided to clinicians caring for a large proportion of socially disadvantaged patients, like Eta, to prevent further disparities and marginalization. Second, CMS should make efforts to compare clinicians with similar patients, thereby ensuring appropriate reimbursement to those truly providing equitable and quality care. The goal is to level the playing field and encourage clinicians caring for patients particularly impacted by social determinants of health.

Cameron Gettel is an emergency physician.

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