Every day, our healthcare system spends $11 billion. As a practicing physician, it is clear that what our system measures and pays for–via diagnosis and billing codes, "allowable services" and myriad quality measures—is a reflection of both what and who it values.
We on the front lines of healthcare know that reducing total cost of care and achieving health equity are only achievable by addressing the social drivers of health—critical comorbidities such as food insecurity and housing instability.
Yet, this is not how our system operates. Under federal payment and quality frameworks, the healthcare system codes, screens, measures and risk-adjusts for diabetes, but not for food insecurity—even though diabetics who are food insecure have worse health outcomes and cost on average $4,500 more per year than those with access to healthy food. A system that does not collect and act on food insecurity data cannot address rising healthcare costs or reduce racial disparities, especially given that Black Americans face the highest rates of both food insecurity and diabetes.
Likewise, the social drivers lead to physician burnout and effectively penalize physicians caring for affected patients via lower MIPS scores. A recent study found that SDOH were associated with 37.7% of variation in price-adjusted Medicare per beneficiary spending between counties in the highest and lowest quintiles of spending in 2017. Yet even with an ongoing pandemic that has painfully brought these issues to the fore, SDOH are still not included in any geographic adjustment or cost benchmarks.
For more than a decade, The Physicians Foundation—directed by doctors from 21 state and county medical societies—has been on the vanguard of recognizing and acting on these challenges. Most recently, we identified four key principles and associated actionable policy recommendations for how to address SDOH in how we pay for and deliver care to improve health, while reducing costs and easing administrative burdens on physicians.
One key principle is the imperative to create new standards for SDOH quality, utilization and outcome measurement. Every year, the Centers for Medicare and Medicaid Services invites recommendations for new measures aligned with the agency's priorities. Consistent with its commitment to identify new measures that are meaningful to patients and providers, reduce the number of Medicare quality measures and ease the burden on users, CMS recently declared a priority to "develop and implement measures that reflect social and economic drivers."
In response, The Physicians Foundation submitted the first-ever SDOH measure set for consideration by CMS, focused on screening patients for food insecurity, housing instability, transportation, utility needs and interpersonal safety. These measures are well tested, including through the Accountable Health Communities model, which has screened nearly a million beneficiaries for SDOH in over 600 clinical practices. Recognizing the imperative to re-balance quality measures to focus on SDOH—which drive 70% of health outcomes and associated costs—we further recommend that for every such measure adopted, CMS retire at least three other process and/or efficiency measures.
In July, CMS officially included these proposed SDOH measures for consideration for two key federal payment programs for clinicians. As context, between 2013 and 2020, 2,864 measures have been submitted for consideration through this process—yet not one has addressed food, transportation and other social drivers of health.
These proposed SDOH measures still have critical milestones to clear via the National Quality Forum Measure Applications Partnership, but if made official, they would be the first federal SDOH measures in the history of the U.S. healthcare system. If they fail in this last mile, CMS' measurement gap will persist—and, more importantly, we will lose the long overdue opportunity to bridge the realities of patients' lives and physician practice and the regulatory machinery of our healthcare system.
With an administration committed to operationalizing equity; a pandemic that has exacerbated rates of food insecurity, housing instability and other social drivers of health and the clinical disease burden linked to these factors; and the Medicare Trust Fund projected to be insolvent in five years, now is the moment to insist that these SDOH comorbidities be recognized and acted upon.
