Understanding the Intersection: SDoH and CMS Star Rating Quality Measures – MedLearn Publishing

We begin by defining the two key elements of this topic. Social Determinants of Health (SDOH), as established by the World Health Organization, are the conditions under which people are born, grow up, live, work and age. These conditions can greatly affect a person’s health, quality of life, and even lifespan. They include factors such as socioeconomic status, education, neighborhood and physical environment, employment and social support networks, as well as access to health care.

On the other hand, the Centers for Medicare and Medicaid Services (CMS) Star Rating Quality Measures is a system designed to measure the quality of health care services provided by hospitals and health plans. These assessments take into account factors such as health outcomes, access to care and beneficiary satisfaction.

The intersection of these two elements is crucial, as CMS star ratings not only impact the quality and type of care patients receive, but also reimbursement rates for healthcare providers.

What becomes clear is that social determinants of health can greatly influence these star ratings. For example, consider transportation access, a typical SDOH. In areas with little public transportation or in rural regions where medical facilities are few and far between, patients may find it difficult to have regular checkups or receive necessary treatments. This lack of access to care can directly impact many of the star rating measures, such as preventive care and chronic disease management, resulting in lower star ratings.

Similarly, consider another SDOH, level of education. Research has shown a correlation between lower education and poor health outcomes. Less education can translate into less understanding of medical information and instructions, leading to less adherence to prescribed treatments and worse outcomes. This, in turn, may negatively impact the star rating based on health outcomes and patient satisfaction.

However, it is important to note that CMS is increasingly recognizing the impact of SDOH on health outcomes and patient satisfaction. In recent years, CMS has made efforts to incorporate SDOH into their models, considering factors such as income, education, and the environment. This is a promising step in addressing these critical health influences.

One such potential effort is the significant change announced in the Prospective Hospital Payment System (IPPS) draft rule for fiscal year 2024. In this draft rule, CMS has made an important advance by including the social determinant codes of the health for the homeless, which will be classified as a complication or comorbidity (CC) if the draft standard reaches final version (usually in August).

The specific codes are as follows:

  • Z59.00 for unspecified homeless,
  • Z59.01 for the protected homeless e
  • Z59.02 for the homeless homeless.

The inclusion of these codes means that health professionals will now have financial incentives to screen and document homelessness. This is a huge step towards understanding and addressing the impact of homelessness on health outcomes.

Homelessness is a profound social determinant of health. It is associated with a number of health problems, including chronic disease, mental disorders and higher mortality rates. Homeless people often face barriers to accessing quality healthcare, further aggravating their health conditions.

However, under the new draft IPPS standard, providers can now be reimbursed for the extra care these people need. For example, a homeless person may need more time, resources, or specialized interventions to manage a chronic condition than a housed individual. Now, CMS recognizes these challenges and compensates vendors accordingly.

Additionally, this change also helps increase the visibility of homelessness as a health problem. Vendors are now being encouraged to document homelessness, contributing to a richer dataset for researchers and policymakers. This data will be critical to understanding the true impact of homelessness on health and how the health care system can better serve this vulnerable population.

This shift in the CMS approach is a significant indication of the growing recognition of SDoH’s role in shaping health outcomes. By financially recognizing the added complexity associated with caring for the homeless, CMS is setting a precedent in how we can make our healthcare system more responsive to SDOH, guiding us towards a future where we can provide comprehensive, accessible and equitable care for all.

However, more can be done.

Health systems and payers must find ways to mitigate the impact of social determinants on health outcomes. This could include innovative solutions such as partnerships with community organisations, investing in social services and embracing technologies to reach patients who may be physically distant from care.

In conclusion, the intersection between SDoH and CMS Star Ratings is a vital issue. Ignoring the profound influence of SDOH can result in lower star ratings, potentially affecting the quality of care patients receive.

Recognizing and addressing these determinants, therefore, is critical not only to maintaining high-quality health services, but also to ensuring equitable care for all, regardless of their circumstances. The healthcare system must evolve to be more sensitive to these factors, integrating them into its improvement and innovation strategies. The new changes to the draft IPPS standard further underline this fact. As we move forward, we need to continue this momentum by incorporating more SDOH into our healthcare practices and policies. Because in the end, a high-quality healthcare system is one that caters to everyone, regardless of their social or economic conditions.

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