Successful Government Value-Based Health Care Requires Continued Attention to Social Risk Factors

Updated on August 7, 2017

As a new administration takes charge and new leadership is appointed for government health agencies, there are significant discussions happening about the future of our health care system. One approach that continues to be discussed, with generally bipartisan support, is the ongoing pursuit of value-based care models, which require dedicated attention to patients, a focus on outcomes and consideration for the social influences that shape population health.

Understanding social influences has been a key driver of an overall shift to a more patient-centric approach, and an issue that the Department of Health & Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) and Congress have worked to better understand over the last several years.

In October 2014, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which required the review of evidence linking social risk factors such as socioeconomic status (including income and education level), race, ethnicity, gender, sexual orientation and the community within which patients live with performance under existing federal payment systems. The report, delivered to Congress in December 2016, showed that beneficiaries with social risk factors had worse outcomes on many quality measures (with dual enrollment status being the most reliable predictor of poor outcomes) and that providers that disproportionately served beneficiaries with social risk factors tended to have worse performance on quality measures.

These are troubling results, particularly because social risk factors have been shown to disproportionately affect minority populations, and are often concentrated in inner-city and rural communities. We need to understand how these risk factors impact health outcomes in order to fairly and accurately measure value-based care. Otherwise, as Drs. Melinda B. Buntin and John Z. Ayanian note, “Medicare quality reporting and payment programs that financially reward or penalize health care providers according to the health outcomes of their patients will understate the quality of care provided by clinicians and organizations that disproportionately serve these populations and give fewer resources to safety-net providers…. If providers are unfairly penalized for serving socially disadvantaged patients, access to care and quality of care for these patients could suffer, and health disparities could widen further.”

These studies are critical steps for determining what value-based care looks like for government, providers and patients, and standardizing metrics across providers, beneficiaries and payors. Considering the full scope of the patient population across ages, races, genders, cultures, geographies, socio-economic statuses and other variables will be essential to setting the benchmarks and standards for success.

Embracing patient-focused outcomes

The heart of value-based care is patient-centered care. Today’s health care consumers are more proactive and engaged in their own care, and they increasingly expect more from their health care providers, so a patient-centered approach is key to achieving successful outcomes, both from their own perspective and from quantitative data measurements. Their care must also be coordinated between providers and patients, with both parties working together in planning, developing and monitoring of care to ensure it meets their full scope of needs.

Outcomes are impacted by the ability to access care and to comply with clinical recommendations and hinge on the system’s ability to recognize and address social determinants of health to remove barriers to achieving health goals for patients. This means being flexible in putting patients and their families at the center of decisions and seeing them as decision-makers in their care, working alongside professionals to achieve the best results.

As HHS, CMS, the Defense Health Agency (DHA) and Congress reevaluate value-based care under the new administration, social determinates must continue to be included as an important factor in establishing measurable outcomes. In order to see outcomes that look beyond CAHPS scores satisfaction surveys and Healthgrades, there must be a focus on the patient experience, as well as how to measure those factors relative to their overall health. At the same time, we must understand that for certain populations, like the aging, outcomes are often about management, not just a cure – and health care providers must identify, prioritize and incentivize quality care.

Working together to implement value-based care

HHS Secretary Tom Price has voiced concerns about the pace at which MACRA and value-based care standards have been implemented to-date, and it seems likely that these will remain a focus in his role at the agency.

In order to speed up the effective adoption of these practices—and ensure that our health care resources go toward removing barriers to health care and delivering and measuring services that provide impact—government and industry must both continue to address the social risk factors that impact the access and delivery of health care, and use that to define the metrics by which providers will be measured. When that happens, our system will truly begin to exercise the patient-centric approach to care that is fundamental to achieving positive health outcomes.

A government and industry partnership can help to create a collaborative environment that can lead to innovative applications of the model and help achieve clarity around how these standards for success will be achieved and measured. Most of all, the success of a value-based care model includes improvement in providing access to quality health care for all people, while effectively managing costs.

Tom Naughton is President of Citizen Health Services at MAXIMUS Federal.