Thread by @WillBleser

Issue brief THREAD: addressing #SDoH through #ValueBasedPayment #HealthPolicy

I'm SUPER excited about this piece. Work began ~8 months ago, I led it, a topic I care a LOT about (and which the Biden administration does, too). @DukeMargolis @MilbankFund

milbank.org/wp-content/upl…

https://twitter.com/DukeMargolis/status/1357708802158641154

THREAD 1/

Alright, finally had a day this week without 200 meetings 😅 so I have time to give this very important topic its proper twitter download. Tweets incoming.

#HealthPolicy #SDoH #PaymentReform #ValueBasedCare

2/ Preface: Important to acknowledge differences in language
-"SDoH:" structural factors shaping downstream social factors
-"Social risk factors:" individual adverse SDoH
-"Social needs:" patients' preferences for help w/social risk factors

#HealthPolicy #SDoH #PaymentReform

3/ It can be difficult to use terms correct, esp. in briefer venue. We discuss programs that screen for #SDoH to understand social risk factors of local pop, then use #ValueBasedCare delivery & payment flexibility to design programs to try to address social needs. #HealthPolicy

4/ And we may not have done so perfectly. Our focus is summarizing landscape of these programs, how to pursue them more sustainably (e.g., Medicaid reform like NC's "Healthy Opportunities Pilots"), and practical guidance on what's known about implementation, overcoming challenges

5/ Nonetheless, we hope our work distilling >100 sources to 9 pages of an issue brief w/a lens for practical guidance & easy-to-understand language will reach states, policymakers, clinicians, payers, community-based organizations to more systematically address unmet social needs

6/ Last preface, major thanks to:
-@RWJF for supporting this work (esp. @khemp64!)
-@MilbankFund for publishing/elevating it, incl. nice layout!
-@DukeMargolis crew: @Hannah__Crook, @whitagarr, @jlmasand, Rob Saunders, James Zheng
-@kejoynt, Mark McClellan for feedback

7/ Impt BACKGROUND:
-Large shift to value-based payment (VBP) over last decade (now ~36% of all health care $$s)
-VBP programs/models that fail to address social needs may be less effective. Building momentum but still nascent

#HealthPolicy #SDoH #PaymentReform #ValueBasedCare

8/ Impt BACKGROUND:
-Fee-for-service reimbursement (still dominant system) severely limits addressing social needs (plus other major issues in cost, quality)
-VBP models=financial+care delivery flexibility to (accountably) do so

#HealthPolicy #SDoH #PaymentReform #ValueBasedCare

9/ Impt BACKGROUND on evidence of social needs interventions in health care:
-Overall, limited but mostly positive
-Health+CBOs working on housing or nutrition=stronger evidence (incl. RCTs) for cost reduction, ROI

#HealthPolicy #SDoH #PaymentReform #ValueBasedCare

10/ Impt BACKGROUND on evidence of social needs interventions in health care:
-Health+CBOs working on non-emergency medical transport=moderate evidence (nonrandomized trials,
DiD studies, cost-benefit analyses) for cost reduction, ROI

#HealthPolicy #PaymentReform #ValueBasedCare

11/ Impt BACKGROUND on social needs interventions in health care:
-Health+CBOs working on OTHER #SDoH domains (e.g., home mods, high-touch care mgmt, legal/financ./social counseling)
=
limited/unclear but growing evidence (few studies, less rigorous methods, or mixed findings)

12/ Impt BACKGROUND on social needs interventions in health care:
-Often context/pop-specific (e.g., chronic homelessness w/high ED use)
-Focus on process measures (e.g., # screened/referred to social needs program)--need more years follow-up
-Many time-limited interventions

13/ Impt BACKGROUND on evidence of social needs interventions in health care:
-Limited info on practical guidance for implementation!

Good news:
-new innovative payment models launched/launching to address social needs
-these can improve sustainability, generate better evidence

14/ how we conducted this study

Worked w/librarian on systematic review of
1. peer-reviewed lit (PubMed+Web of Science)
2. gray lit (Google)

Paired w/
3. scans of state health policies
4. payment reforms proposed to Physician-Focused Payment Model Technical Advisory Committee

15/ Mechanisms to address social needs through VBP:
-Traditional Medicare generally cannot pay for
-CMMI has/is using legal authority to test SDoH screening, referring, addressing (e.g., Accountable Health Communities, SIM awards) but limited design so far.

#SDoH #ValueBasedCare

16/ Medicare Advantage can optionally offer expanded "health-related" supplemental benefits since 2018, incl. food, pest control, indoor air quality equipment, structural home modifications.

Read our other brief on just that topic: healthpolicy.duke.edu/sites/default/…

#SDoH #ValueBasedCare

17/ Mechanisms to address social needs through VBP:
-Commercial plans are innovating, too, looking to improve value--though #SDoH services limited by what counts as medical expenses in their MLR, and also public info is limited on this.

#HealthPolicy #SDoH #ValueBasedCare

18/ Brings us to state Medicaid programs; they have the most structural avenues to address social needs, and where perhaps most impressive efforts occurring!
-state plan amendments (like case management benefit)
-1115/1915 waivers
-other VBP contracts (like Medicaid ACOs or MCOs)

19/ Groundbreaking 1115 waiver to begin in North Carolina: Healthy Opportunities Pilots.
-MCOs+CBOs req'd to tackle 4 #SDoH domains
-$650 million to be invested
-⬆️VBP as progresses

PS: We're studying this! (read: academyhealth.org/page/supportin…)

cc @ncdhhs @SecMandyCohen @amvanvleet

@ncdhhs @SecMandyCohen @amvanvleet 20/ Even more via Medicaid ACOs or MCOs. These plus 1115 waivers are ways to more sustainably address social needs through VBP (esp. if directly tied to performance, like in NC).

Key examples: @OHAOregon's CCOs, @RIHEALTH's Medicaid AEs, @MassHealth/@Mass_HPC's MassUP.

/21 in just Medicaid programs (public reporting=can know denominator/geographic spread):

18 states +DC have taken at least foundational steps toward statewide VBP initiatives that directly address SDoH needs. (i.e., excluded states only requiring identifying social needs).

22/ Of these 18 states +DC, most did not explicitly require or provide financial resources for the SDoH services or the SDoH services were optional.

So @ncdhhs’ Healthy Opportunities Pilots and @OHAOregon’s CCO 2.0 program are positive outliers.

BUT lots to look forward to!

23/ other takeaways, landscape of VBP for #SDoH
-more urban (rural will need sig $$ for VBP+CBO networks)
-different models (ACOs, MCOs, global budget); advanced, prospective models would foster payment/delivery flexibility
-savings time for SDoH ≠ typical VBP timeframe (3+ yrs)

24/ So... what do payers:providers need to do to address social needs vis VBP?

4 key themes of challenges and strategies crystallized from journal/grey literature:
1. data collection+sharing
2. social risk factor adjustment
3. cross-sectoral partnerships
4. org. competencies

25/ PS, not even close to done this thread! I've just *introduced* the 4 key themes around challenges+strategies for implementing VBP to address social needs. Back on this (most impt part) ASAP!

(Had a big virtual mtg yesterday with external stakeholders for one of our grants)

26/ Alright, finally found more time, so BACK ON IT!

Theme 1 of what payers/providers need to do to address social needs via VBP:

1. data collection+sharing. Without smooth data exchange, health care orgs/CBOs limited in ability to refer people for social needs interventions.

27/ Major challenge: no standardized screening tools for social needs, social risk factors.

However, there are several national efforts to compare, streamline, and standardize tools! So there are common places from which to start planning data use and screening for social needs:

28/ Technology platforms for cross-sectoral referrals are unsurprisingly the next big piece.

Innovative public-private example: NC launched NCCARE360 statewide. Provides bidirectional referrals for med & CBO services, follows-up to see if service provided or new referral needed

29/ Add’l challenge: multiple, differing legal/regulatory hurdles to cross-sectoral data collection, exchange. e.g., Health Insurance Portability & Accountability Act (HIPAA) vs Family Educational Rights and Privacy Act (FERPA)

Need: creative federal streamlining, thinking here.

30/ Sum of theme 1–data collection and sharing strategies and solutions below. Progress, statewide or federal examples of innovative work and efforts to solve them, but still a work in progress. #SDoH #ValueBasedCare #PaymentReform #HealthPolicy #PublicHealth

31/ Theme 2, what payers/providers need to do to address social needs via VBP

2. Social risk factor adjustment

Most VBP models *medically* risk adjust (ex: HCC scores) to ensure clinicians fairly compared on care quality (prevent sicker patients=worse quality/model performance)

32/ So naturally, must adjust for social risk factors so VBP providers in social needs accountable models compared on care quality, not penalized for caring for pops w/higher social risk

We did it medically via HCC so social risk factor adjustment should be easy, right? WRONG!

33/ One challenge is that, conceptually, #socialriskfactor adjustment remains controversial. Some argue it allows for lower quality care for marginalized populations. Yet others argue it can prevent clinicians from being penalized for serving more medically, socially complex pts

34/ In fact, it is true that clinicians serving more homogeneous, resource-rich areas generally perform better than safety-net facilities under current VBP models.

That is both an equity problem and a call for social risk factor adjustment—when we better know how to, that is...

35/ Known operational issues with social risk factor adjustment:

- simpler algorithms w/available data (e.g., use %dual-eligibles) have not been accurate

- CMS experimenting within current data limitations and cautious methods—but studies worry will be ineffective (more below)

36/ Worth noting, though, positives! 1. @HHS_ASPE continues to convene experts to make recs on social risk adjustment (cc @kejoynt!); 2. Similar effort by @NatQualityForum; 3. Other state-based and federal examples trying to solve this locally or within certain pops (see below).

37/ and—at the very least, while waiting for further guidance from promising efforts—stratify measures by sociodemographic characteristics to provide meaningful information that delivery orgs can use to target improvement efforts and understand variation.

Theme 2 summary:

38/ two more themes to go re: what payers and providers need to know about addressing social needs through VBP, but for now—bed time for me!

Stay tuned tomorrow for summary of challenges and strategies on:
3. Cross-sectoral collaboration
4. Building organizational competencies

39/ Theme 3, what payers/providers need to do to address social needs via VBP

3. Cross-sectoral collaboration

Unsurprisingly, for health system (via VBP) to address social needs, health system must work with... you guessed it: the social services system!

#SDoH #HealthPolicy

40/ Health system must explicitly acknowledge & account for, though, that social services have been sitting at this "table" for... ever. And other health folks have been sitting at the table for many decades (like #publichealth). Health care is *new* to the table. Notes on that:

41/ Health system typically brings huge $s to table (relative to social services, public health)

v important to note: financial insolvency *major issue* in social/human services CBOs

Chronic underfunding+aggressive funds competition
=
power dynamic+CBOs often undercut $ needs

42/ Cross-sectoral collaboration challenge 2: Health and social service sectors also have differing histories, processes, cultures, and even terminology for same concepts.

Challenge 3: new health $s/programs may "crowd out" people on CBO wait lists but not part of program...

43/ Cross-sectoral collaboration challenge 4: could be major CBO network inadequacy in rural areas, or smaller/resource-constrained CBOs may lack the infrastructure or data that health system leaders want before partnering.

Lots of challenges #SDoH #HealthPolicy #ValueBasedCare

44/ Good news: big lit. on sustaining cross-sectoral health collabs! (Ex: helpful figure of strategies below from this review pubmed.ncbi.nlm.nih.gov/26429834/). Other ex's:
-acknowledge tensions, power imbalance
-use health system power to request diverse funds
-use 3rd party convener

45/ Summary of the implementation challenges and strategies for theme 3 of what payers/providers need to do to address social needs via VBP: cross-sectoral collaboration.

#SDoH #HealthPolicy #ValueBasedCare #PaymentReform #SocialNeeds #HealthCare #HumanServices #SocialServices

46/ Final theme, what payers/providers need to do to address social needs via VBP

4. Organizational competency building

It's not just CBOs that need help in VBP competencies: so do clinicians & health orgs! Esp. smaller, rural, safety net, or otherwise resource-constrained orgs

47/ For payers: upfront capital to stand up VBP infrastructure really helps (good study here on CMS prog: pubmed.ncbi.nlm.nih.gov/31291511/).

States can help a lot, too. Details in image from @Mass_HPC's CHART investment program, @HealthNYGov's Behavioral Health VBP Readiness Program.

48/ Summary of the implementation challenges and strategies for final themes of what payers/providers need to do to address social needs via VBP: building org competencies.

#SDoH #HealthPolicy #ValueBasedCare #PaymentReform #SocialNeeds #HealthCare #HumanServices #SocialServices

49/ It took me 49 tweets to summarize #HealthPolicy addressing #SDoH through #ValueBasedPayment. I actually tried to be brief😅😂 but goes to show complexity.

Nascent field, implementation challenges, but with groundbreaking models about to begin, massive potential.

In sum: