Social determinants of health data challenges and their impact on risk and quality

The impact of social determinants of health (SDOH) on patient care is becoming more and more critical. Over the past few years, the Centers for Medicare & Medicaid (CMS) has focused on addressing SDOH for all members. This shift may affect risk and quality success and requires an evolution in coding capabilities within existing documentation systems.

Social determinants of health and their impact on Medicare Advantage risk adjustment were discussed during the monthly webinar series, The Path to Risk and Quality Success. Leading the webinar was Tania Miedico, MD, CRC, Clinical Performance National Medical Director of Optum and Jim Dolstad, ASA, MAAA, Vice President, Actuarial Consulting.

Defining social determinants of health
There is no one comprehensive list or definition of what the SDOH are. Here are two of the most established definitions. Both definitions contain some common environmental conditions that affect health care and ultimately outcomes:

  1. Social determinants of health are conditions in the environment in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks.
  2. The social determinants of health are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.

Are health plans prepared to address SDOH?
We asked webinar attendees if their organizations were prepared to address SDOH. Poll respondents were fairly well split, with 43.9% of organizations ready to deploy strategies and 39.5% still in the planning stages to address SDOH.

Addressing SDOH through Medicare Advantage
We can expect more to be done around SDOH as Medicare Advantage is uniquely positioned to address. There is a strong incentive for MA plans to focus on primary care, prevention and care management. The 2020 Final Call Letter included language about having more opportunities and flexibility within MA plans to address social determinants.

Fee-for-service (FFS) Medicare can benefit by addressing SDOH from an outcomes perspective and potentially lowering premiums. Medicare Advantage is encouraged to do this through plan design as well as the health care information that can be leveraged to improve revenue for Stars and risk adjustment.

Understanding social determinants proactively
Health plans can be proactive when it comes to addressing social determinants of their at-risk members. When you know the member as a customer not just a patient, you can find ways to get data to interact in workflows, assessments and clinical quality. As a better picture of the member forms, you can work smarter to understand clinical impactability and willingness to engage to change behavior and help close gaps in care.

Use results from consumer analytics, actuarial, underwriting, account management, clinical, population health management and quality programs to help you understand areas of opportunity such as:

  • Utilization — Reduce hospital admission, readmission and emergency room use.
  • CM/PHM — Develop a more sophisticated identification strategy and engagement approach for clinical and behavioral programs.
  • Quality — Improve Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Healthcare Providers & Systems (CAHPS®), Health Outcomes Survey (HOS) and medication adherence.
  • Risk profiling — Use non-clinical characteristics to develop more robust risk profiles.
  • Underwriting — Use non-clinical characteristics to inform underwriting decisions.
  • Benefit design — Use non-clinical characteristics to develop more meaningful, effective benefits.

ICD-10 codes and SDOH
There is a lack of ICD-10 codes for SDOH, which reduces the ability to identify and monitor social determinants. Without proper monitoring, you can’t track what members will need.

Currently, work is being done so additional ICD-10 codes can account for more situations and scenarios. This will help health plans and providers understand the social determinants that impact member health and help improve health outcomes.

Make sure providers are aware that there are some ICD-10 codes they can use. CMS quoting guidelines allow for non-clinicians to use these codes for members. Coders in your organization should review these codes and be a part of the discussions on the best way to educate providers on the available codes.

Partners in the solution
There are two partners that are part of the solution to ensure we have the amount of codes needed to best document social determinants:

  1. Project Gravity within the Social Interventions Research & Evaluation Network (SIREN) is a national collaborative effort looking to reduce the barriers to social risk and protective factor documentation. Through Project Gravity, use cases are being developed to get consensus so clinicians, together with health plans, can collaborate to make recommendations about which codes should be added.
  2. The Da Vinci project has a goal to help health plans and providers positively impact clinical, quality, cost and care management outcomes. They are working together to accelerate the adoption of Health Level Seven International, Fast Healthcare Interoperability Resources (HL7® FHIR®) standards to support and integrate value-based care (VBC) data exchange across communities. They want to make sure there is interoperability within technology solutions as we continue to use data to improve social determinants.

Using in-home assessments
Being in a patient’s home offers a unique opportunity to identify SDOH and document barriers to better health. Clinicians performing in-home assessments can spend more time with members and create referrals to address SDOH they observe. Ensure your vendor has a space within their documentation to capture those SDOH and uses clinicians who are trained to identify SDOH.

6 steps to take now
There are 6 steps you can take now to start engaging in strategies to address social determinants:

  1. Educate providers on current ICD-10 codes available and their appropriate use.
  2. Keep informed — the final report from the National Academy of Sciences, Engineering and Medicine contains a lot of information how our government agencies are thinking through the social determinants.
  3. Participate in the Gravity and the Da Vinci projects so your voice is heard.
  4. Use in-home assessments to document SDOH and generate appropriate referrals.
  5. Leverage indices to know your customer not just your patients, to manage your population proactively.
  6. For more information on SDOH, visit the Centers for Disease Control SDOH website.

On-demand and upcoming webinars
Please visit our Path to Risk and Quality Success webinar series page to explore upcoming topics, register for the next monthly webinar or watch one of our other webinars in this series on demand.

If you were unable to attend the webinar on social determinants of health or one of our other webinars in this series, you may watch on-demand.


Meet the Authors

Tania Miedico, MD, CRC
National Medical Director, Clinical Performance, Care Services

Dr. Tania Miedico is a Board-Certified Family Medicine Physician and a Certified Risk Adjustment coder. She currently has responsibility for risk adjustment programs as a Medical director with Optum. Previously, she led the OptumCare Clinical Performance Education Solutions team where she developed coding and documentation education initiatives and provided clinical insight for the development of data analytics programs.

Formerly, Dr. Miedico served as the Associate Medical Director for ACE and Health Informatics at Southwest Medical where she worked to integrate Lean principles into physician workflows and optimization of EMRs.

She graduated from the University of Puerto Rico Medical School and completed her residency in Family Medicine at Florida Hospital (now AdventHealth) in Orlando.


Jim Dolstad
Vice President, Actuarial Consulting

Jim’s expertise is total cost reduction, leveraging social determinants, next-generation underwriting, population health management, program evaluation, performance management, Stars, predictive modeling and risk adjustment.

Jim has more than 30 years of industry experience working with payers, providers and employers. Prior to joining Optum, Jim was the chief actuary for a global operations management and analytics company. He also has served as chief actuarial officer.

Jim earned his Bachelor of Science in mathematics and economics from the University of Puget Sound. He is an associate of the Society of Actuaries and a member of the American Academy of Actuaries.

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