Family physicians take a comprehensive approach to health care, but Medicare payments do not adequately account for their attention to social determinants of health. A new report suggests ways that could change.
The report (www.nap.edu) by the National Academies of Sciences, Engineering and Medicine -- the latter formerly known as the Institute of Medicine -- titledAccounting for Social Risk Factors in Medicare Payment identified ways that Medicare could incorporate several social risk factors into a value-based payment model. The authors make detailed recommendations about data CMS could begin collecting to bridge the gap between patients' social conditions and their health outcomes.
Most of the data relate to demographics such as ethnicity, education, marital status and income that could be collected when patients apply for Medicare. Education data, which CMS does not currently collect, might indicate whether patients can access and understand health information, make proper decisions about their health, and be an advocate for healthy behaviors.
Other data sources are "neighborhood deprivation" measurements that provide snapshots of factors such as transportation options, walkable spaces, health care availability and violence. Housing quality is a particularly important factor in patients' health.
"Poor quality or unsafe housing can expose individuals to such environmental hazards as lead, poor air quality, infectious disease and poor sanitation, and can lead to injury," the report stated. "Currently, neither CMS nor providers and plans routinely collect housing information."
The report also addresses how data can be captured directly from the patient. Smartphones and wearable devices could report fluctuating health data to medical staff and insurers. But as promising as such technologies are, the authors do not expect them to change the payment system in the near future.
"It is unlikely that technologies and interoperable systems will be available for patients to directly, systematically and securely submit social risk factor data to CMS for use in Medicare payment," the report stated.
Family Physician Puts Spotlight on Payment
One family physician welcomed the report and the move toward building a comprehensive patient profile, noting it illustrates the importance of full-spectrum patient care.
"It shows they are well aware of the added burden of caring for patients with limited resources and the challenges it can bring, especially in light of payment reform," Shannon Dowler, M.D., a family physician in Asheville, N.C., told AAFP News. She serves as medical director for primary care clinical programs for Mission Medical Associates and faculty for the Mountain Area Health Education Center family medicine residency program.
Collecting additional data will require a major staff commitment from physician practices. To reduce this burden, the report said that before considering new requirements for electronic health records, CMS should use the data that it and/or other agencies already possess, or the agency should collect data during enrollment. Physicians should be compensated for collecting additional data, Dowler said.
"Data collection and documentation has a cost," Dowler said. "If we are going to rely on medical practices to be an important touch point for data, there needs to be payment for the screening process."
Dowler emphasized that CMS also needs to help build infrastructure and a communications strategy so primary care physicians and their community partners can create a system that wraps around the patient.
For instance, Dowler said one of her patients, a woman in her mid-50s, lives alone in a trailer. She has advanced lung disease and her home is contaminated by mold, but neither she nor her relatives are able to pay for necessary repairs. Dowler has been trying to help her find assistance.
"How do we pay for that?" Dowler asked. "How do we find the resources to change that living environment? It's not something we can control in a medical practice. It's one thing to measure social risk factors, but if we're not prepared to do something about what we discover, then we lose some of the value of collecting (information about) them."
Another important factor is access to medical services, which may require rural residents to drive 30 minutes or more to reach a physician's office or pharmacy. Mobile units that visit underserved neighborhoods or offer annual screenings are a starting point, but Dowler said visiting just once a year for a few hours will not improve a community's overall health. And she noted that some patients live in environments that are unsafe for medical staff to visit because of recurring violence or drug trafficking, adding obstacles to providing care.
"We cannot expect the current health care system to work for everyone, especially our most marginalized populations," Dowler said. "We have to be willing to turn it upside down and be willing to go where the patients are and put health care resources directly in the most vulnerable communities."
Start With the Basics
The report notes that CMS could begin building a social risk map by using the most basic data the agency has for every patient: a residential address. Steven Crane, M.D., of Hendersonville, N.C., told AAFP News that where he practices, high-risk diabetes patients are typically concentrated in just three or four census tracts.
"Two patients from a low-income background could look really different depending upon where they live," said Crane, a family physician and medical director at Appalachian Mountain Community Health Centers, a federally qualified health center.
Crane suggested a map of high-risk patients using addresses also could highlight food scarcity, nearby health care services and area violence. It would be easier to build than a database that captures all the individual risk factors independently.
Once the map is built, a monthly capitation payment could serve as an incentive for physician practices to take on high-risk patients in vulnerable neighborhoods. Crane said a payment or a "social disparity code" between $25 and $50 would be appropriate.
"I could hire a community health worker" with such a payment, Crane said. "The community health workers we employ cannot change the violence in a community, but they can help with medication and transportation."
If CMS is interested in improving the health of a population that is more complex, he said, "then it is time to start changing the model of care."