Hospitals want readmissions program to account for social determinants

Hospitals, particularly safety net providers, are calling on the CMS to better account for patients’ social risk factors in the long-standing readmissions penalty program, but achieving that anytime soon faces hurdles.

“We are still getting our arms around the best data to collect on social risk factors and the mechanism to collect it both for the purposes of improving quality measures and their accuracy and validity for use in patient care,” said Akin Demehin, director of policy at the American Hospital Association. 

The 21st Century Cures Act gave the CMS authority to change the program to account for patient social risk so it’s possible for the agency to incorporate social determinants of health. The big question is how to do that. The CMS is already separating hospitals by dual-eligibility status in the Hospital Readmissions Reduction Program; hospitals say that’s just a first step.

Agency officials did not respond to a request for comment on whether or not it’s currently working on ways to implement social determinants of health in the program. 

Hospitals are moving ahead with efforts to address social determinants to avoid penalties in the readmissions program with varying levels of success. For instance, Beaumont Hospital in Wayne, Mich., implemented a process to identify social determinants that has helped slow readmission rates, said Dr. Sam Flanders, chief quality officer for Beaumont Health. A social worker now rounds in the family medicine department to assess patient needs and help inform staff what actions need to be taken both in the hospital and when the patient leaves.

With only six months of data, Flanders said the results look good so far. But deploying a program across a health system won’t be simple. For instance, Beaumont’s hospital in Royal Oak, which was hit with large readmission penalties in 2017, also has some of the lowest mortality rates in the country—five out of six of its 30-day mortality measures are in the lowest quartile of all U.S. hospitals rated by Modern Healthcare Metrics. Flanders believes the two go hand in hand in reducing the facility’s readmissions score.

Patients in Royal Oak face poverty, homelessness, food insecurity and inability to afford medications or follow-up appointments, among other things. And although Beaumont is making efforts to address patients’ social risks, incorporating social determinants of health into the readmissions program would help, Flanders said. He also thinks the hospital should be given a break due to its low mortality rates. 

Demehin said the CMS is likely waiting for more research before it changes the program. The Impact Act mandated two federal studies to explore how social risk factors affect performance in the CMS’ value-based purchasing programs. The final study is set to be published in October.

Rather than wait for more research, the CMS has other data sources it can use now to address social determinants, said Dr. Karen Joynt Maddox, assistant professor of medicine at the Washington University School of Medicine in St. Louis who has studied the readmissions program. 

The easiest way for the CMS to get this data is via claims, which, along with patients’ dual-eligibility status, contain addresses and the age when they first obtained Medicare coverage. The frequency of address changes can illustrate housing stability and receiving Medicare coverage before age 65 indicates a disability. 

There are also medical factors hospitals report to the CMS that could indicate social risk factors, Maddox said. For instance, frailty and mental illness are usually indicators of worse health outcomes for a particular condition, and those with worse outcomes tend to be lower income. Getting at the issue by looking at medical conditions is also less political than using social disparities, she added, saying, “It doesn’t come with the baggage of talking about disparity.”

The CMS could also tap into results from screenings that more hospitals have begun to conduct to understand patients’ social determinants of health, said Maryellen Guinan, senior policy analyst at America’s Essential Hospitals, which represents safety-net hospitals. 

Guinan said her association doesn’t want the CMS to mandate a screening tool for hospitals; without such a tool it’s unclear how the CMS would get the information in a standardized way.

Maddox said using screening results would be ideal because rich personal information about the patient will be gathered, but it’s a long-term goal. It would require creating quality measures based on the screening results in the electronic health record so the CMS could use it. “That is a five-year plan,” she said.

DATA: Largest penalties to urban hospitals for readmissions, 2019