Quality scores like Stars, penalties on readmission rate, and even bonus programs like the now retired PQRS (those were the days!) are designed with the best intentions: creating financial stakes around quality of care in value-based care participation. They help the best show they’re the best and help those facing challenges to improve.
However, the top providers in the world with the most active, engaged payers are facing the limits of what they can do clinically for millions of patients. The care is impeccable, the patient satisfaction is high, but there’s an x-factor that demolishes good outcomes and readmission rates as well as aggregate Stars ratings: social determinants of health.
Today, we’re going share insight into the problem and what individual level social risk data can do to make SDOH-related readmissions addressable and ensure quality scores reflect the actual level of care delivered.
Social Determinants of Health and Readmission Rates
Readmission goes far beyond value-based care, affecting private payer and other commercial arrangements just as much. Annually in the US, $17B in preventable care costs are attributed to hospital readmissions. Of that $17B, $34M are attributed to SDOH alone. The numbers are stark: patients at social risk are more than four times as likely to be readmitted (0.2%) than the average patient (>0.05%).
More damning, when it comes to value-based contracts, that number excludes the payment reduction formula applied based on readmission rates, meaning that $34M is significantly higher.
From the first paper cited above, the findings were grim for popular methods of addressing health related social needs: survey-based approaches were ineffective. We’ve discussed this before, but it deserves reiterating: person-level data available and in aggregate from a variety of sources is the next step in SDOH intervention. It’s also the only way to address SDOH-caused readmission.
A patient with a ride home from the hospital will say they do not have difficulty accessing transportation, but if they can’t drive themselves and are reliant on the availability of friends and family, follow-up appointments, wound care, dialysis, even trips to the grocery store are at risk. The right dataset can uncover what they either will forget or be uncomfortable sharing: how far away they live, whether they own a car or can drive, and their economic access to ride shares. With a provider or care management team already aware of a patient’s social circumstances, these can be addressed before they lead to ED utilization or readmission. This alone can take a significant bite out of that $34M annual cost of SDOH-related readmission, radically improving any federal penalties (or bonuses).
Accurate Stars Ratings and Social Determinants of Health
The Star rating of a plan or risk-bearing provider organization has a significant impact on MA plan rebates and, once it’s high enough, delivers bonuses.
It works as follows:
- 3-Star plans receive a 0% bonus and 50% rebate
- 5-Star plans receive a 0% bonus and 60% rebate
- 4-Star plans receive a 5% bonus and 65% rebate
- 5-Star plans receive a 5% bonus and 70% rebate
- 5-Star plans receive a 5% bonus and 70% rebate
The scores are calculated based on customer service, member complaints, responsiveness and care, chronic condition management, and vaccinations, screenings, and annual wellness visits.
There’s an argument to be made that good insight into social risks of patients can lead to them feeling more comfortable, engaged, and supported. This is accomplished through proactive interventions. However, addressing domains of social risk like food, transportation, and even housing insecurity can be fast, measurable, and focused.
Armed with the right datasets, care management and member engagement teams can act on those more identifiable risks (many of which are also aligned with addressing readmission!) and have an immediate impact on outcomes, avoidable costs, and the factors that directly impact Stars ratings.
Whether through membership churn or the dynamic nature of communities, even an exceptional Star rating needs to be maintained. Engaging members’ social risk to improve health and reduce costs is a moving target susceptible to environmental factors like extreme heat or storms, as well as a shift in the housing economy and stock market.
Knowing who needs what via a dataset that isn’t just granular but frequently updated will keep MA plans and risk bearing providers ahead of the game through any changes and ready to make the most of their contracts through prudent effective actions and delivering the best care possible.
Value-Based Approaches to Commercial Populations with SDOH
While much of what we’ve discussed today does focus on programs that affect value-based populations, better outcomes are better outcomes, and lower costs of care are lower costs of care, regardless of population or market.
The use of proactive, focused SDOH interventions with individual and community-level data is a breakthrough for quality of care across any population, delivering healthier communities and financial peace of mind that, in turn is a competitive differentiator in a competitive commercial landscape.
To learn more, reach out today. We’re here and eager to help you take the next step in care for your members.