Now the real work begins. The new law doesn't include specific guidance on how social determinants of health should be measured and modeled into quality reporting. Determining SES risk adjustment for readmissions will be a significant challenge and remains the open, $500 million question for hospitals.
Of note, the Cures Act calls for creating cohorts of hospitals that care for a similar socio-economic mix of patients—in this case, focusing on patients dually eligible for Medicare and Medicaid. The intent is to compare hospitals with a large percentage of low-SES patients against other hospitals with a similar patient profile. There are a few challenges with this approach, including determining what cutoffs will be used to determine the penalties assessed to each cohort.
Besides cohorts, the CMS should include other demographic factors in determining SES. Evaluating ZIP codes served by a hospital and refining with census data and street addresses would offer greater insights into SES. Another proxy of SES is penetration of school lunch vouchers.
Other factors not currently captured by risk adjustment but influencing readmissions and correlated with low SES include health literacy, proximity of grocery stores with fresh fruit and vegetables and access to public transportation.
No model is perfect, however. Even if a hospital provides proper discharge instructions, ensures medication availability and aftercare beyond a seven-day window, factors outside of a hospital's control begin to have a much larger influence over outcomes. Changing the readmissions measurement period from 30 days to seven days would go a long way to level the playing field for hospitals and better reflect quality of care. The need for socio-economic adjustment would also be minimized.
As the CMS begins developing formal guidance on accounting for SES, we look forward to working with the agency to help steer this much-needed improvement to quality measurement.