The Executive Suite: Barriers to moving to value-based care

With the current administration of President Joe Biden, the U.S. Centers for Medicare & Medicaid Services (CMS) continue to make health equity a key aspect of value-based care. Studies are increasingly detailing how the conditions in which people are born, grow, live, work, and age – what are known as the social determinants of health (SDOH) – have an enormous impact on health outcomes, which we saw play out in COVID-19 cases. In particular, research documents that SDOH inequities are not only directly related to, but are one of the main causes of disparities in health outcomes.

As a result, health providers are increasingly looking at SDOH as comorbidities and are exploring ways to practically integrate SDOH into their care models and recommendations in an attempt to measurably improve patient outcomes.

However, according to The Physicians Foundation’s 2022 Survey of America’s Physicians, six out of 10 physicians said they do not have the time needed during appointments to adequately address SDOH with patients. Providers need effective resources and support to address SDOH. Tooling built on SDOH factors that dynamically changes with new patient information could make that SDOH conversation with individual patients possible, and the tech’s recommendations can be customized to a particular patient, lightening the burden on providers.

CMS and new compliance requirements

Considering SDOH and health equity is now a matter of compliance, too. CMS is requiring – as part of its Accountable Care Organization Realizing Equity, Access, and Community Health plan, known as the ACO REACH model – that health providers identify vulnerable populations impacted by SDOH and then add additional resources targeting members of these populations to address these disparities. Doing so should pragmatically drive health equity in a quantifiable way.

In addition to several compliance requirements, CMS is also adding financial incentives as part of the ACO REACH program.

However, how to implement consideration of SDOH is not detailed by CMS, putting the onus on providers to build or buy a solution that not only meets compliance regulations, but one that actually works.

Risks of trial and error cost ACOs money

From CMS' perspective, the purpose of the regulations on data collection and equity plan requirements is to help ACOs effectively lower costs and improve quality within the new value-based care model. However, CMS has not provided tooling for achieving these desired results.

ACOs might be tempted to do minimal efforts that show a good faith attempt at addressing disparities but without diving into the details of the efficacy of their method. However, a minimal effort and "winging it" approach pose real and large financial risk for ACOs as they could be penalized for failure to comply completely. And here’s the kicker: It’s a risk ACOs don’t have to take if they use the right tooling. They don’t even have to build it themselves.

Data-driven, dynamic approaches work

SDOH is a complex, data-driven discipline, and CMS is approaching it as such. The equity plan requirement is not simply about cobbling together some high-sounding sentences. Rather, it demands a data-driven workflow tool for assessing SDOH for particular patients, tech that can be monitored on an ongoing basis. Such tooling needs to provide actual data for tracking and monitoring outcomes. Even achieving minimal compliance will require a sophisticated and technical approach, one based on data science and engineering.

It’s worth an ACO doing right, right from the start. Even creating the data collection plan to be just minimally compliant is still time-consuming and expensive. ACOs need to understand which patients to target first, and how to maximize survey time. Moreover, having spent all that money on getting the data, ACOs need to know what they are going to do with it to ensure it's not a wasted expense. Quality data analytics of SDOH factors is essential for improved patient outcomes.

Spending money on a data-driven, dynamic tool to analyze SDOH and make recommendations for particular patients will pay out in in favor of ACOs’ bottom line and provide return on investment: When providers have supportive tooling to account for SDOH from the start and design curated plans customized to each patient that are built on SDOH, that patient sees improved health outcomes, which in turn correlates to less cost for providers in the value-based care model.

SDOH act as comorbidities: Treat them as such

Most importantly, ACOs need to take seriously the idea that SDOH act as a comorbidity. In a value-based care model, ACOs’ bottom line depends on it, as does the health outcomes of their patients.

Without a data-driven approach to how to address SDOH on a patient-by-patient basis, ACOs are almost guaranteed to lose money while not actually improving the quality of health outcomes. And providers will suffer as a casualty if effective methods are not employed.

Choosing effective tooling

It’s now PY2023, and time for ACOs to implement a solid health equity plan that will answer to compliance and financial requirements. Here are some questions for ACOs to consider when choosing a plan:

Is the tooling built on considerations of SDOH, or is SDOH just an add on at the end? Tooling that only considers SDOH at the end will likely waste money since it assumes a standardized recommendation and only triages for SDOH after pre-selecting options.
Can the tooling determine SDOH for specific patients? The technology needs to go beyond ZIP codes, more specific than communities, to give a holistic picture for particular patients.
Does the tooling adapt with changing data? For tooling to be effective in practice it should continually update and adjust with new patient information so it can grow with an ACO as new patients join.

Bringing effective tech into ACOs to drive measurable, data-driven health equity results will cost money. ACOs can save by using tooling that is proven and already built, rather than designing their own. At the end of the year, failure to take action will cost ACOs even more: both their bottom line and their patients’ health.