Health Policy Researchers Look at the Challenge… Leave a comment
How difficult will it be to translate health equity concepts into achievable, and importantly, measurable changes in how hospital care is delivered to diverse patients? That’s a question that a team of healthcare policy researchers tackles in a New England Journal of Medicine Perspectives op-ed.
In a blog dated Dec. 29 and entitled “Hospitals and Health Equity—Translating Measurement into Action,” Sahil Sandhu, M.Sc., Michael Liu, M.Phil., and Rishi K. Wadhera, M.D., M.P.P., tackle the subject head-on—and note the complexity of it all. Sandhu and Liu are colleagues at Harvard Medical School in Boston, while Liu and Wadhera work together in the Section of Health Policy and Equity in the Richard A. and Susan F. Smith Center for Outcomes at Beth Israel Deaconess Medical Center, also in Boston.
Sandhu, Liu, and Wadhera begin by noting that “The U.S. health care system ranks last on measures of equity among similar high-income countries. Although policymakers and payers have increasingly looked to hospitals to help reduce inequities, there’s been less focus on their role in addressing health-related social needs (HRSNs). Such needs are related to food insecurity, housing instability, a lack of access to transportation, an inability to afford utility bills, and exposure to interpersonal violence, among other concerns. Despite the strong links between HRSNs and health outcomes, recent evidence suggests that only one quarter of U.S. hospitals screen for these five needs.”
In that context, the researchers write, “To address this issue, the Centers for Medicare and Medicaid Services (CMS) recently announced the adoption of three health-equity measures in the Hospital Inpatient Quality Reporting program. The first measure, which will be implemented for the 2023 reporting period, evaluates hospitals on five domains: commitment to health equity as a strategic priority, collection of sociodemographic and HRSN data, analysis of these data, adoption of quality-improvement activities focused on health disparities, and leadership engagement with equity efforts. The second and third measures will require that hospitals report the percentage of adult patients who are screened for the five HRSNs described above at the time of admission and the proportion who screen positive for these needs.”
The challenge, though, is that “Hospitals will probably require new capabilities and planning to successfully screen for HRSNs, but there’s limited evidence to inform approaches to inpatient screening. Research on the acceptability of screening among patients and providers and the validity and reliability of specific tools has been primarily conducted in outpatient settings. A recent report found that only 2 of 42 implementation studies related to multidomain HRSN screening were conducted in inpatient settings. Nonetheless, there are several steps that hospitals could take to support the adoption of these measures.”
Among the issues the researchers note:
Ø It’s not clear which screening tool or tools to use. The federal Accountable Health Communities Model makes use of “a 10-item tool that encompasses the five HRSNs included in CMS’s new measures,” and that tool has already been used to screen more than 1.1 million Medicare and Medicaid beneficiaries; meanwhile, other tools capture different aspects of the same five HRSNs or address different problems, such as social isolation and immigration-related concerns.
Ø Hospitals will have to figure out how to collect data and who will collect them. As the authors note, “Implementing HRSN screening will probably require substantial financial and human-resource investment to develop workflows, train employees to be attuned to patient privacy and comfort, and consistently administer the screening tool.”
Ø Importantly, the researchers note, “[H]ospitals could integrate screening results into electronic health records (EHRs) to increase data access for clinicians and healthcare system leaders and inform population-level quality-improvement efforts.”
Of course, there is great strategic and process complexity there, as hospital leaders will face a welter of questions around which types of codes to use, related to which standards. The authors state that “Leaders should consider linking responses to codes from the International Classification of Diseases, 10th revision (ICD-10), Systematized Nomenclature of Medicine (SNOMED), and Logical Observation Identifiers Names and Codes (LOINC) that have been recommended by the Gravity Project, a national collaborative dedicated to developing standards for the use and exchange of data regarding social determinants of health.”
In short, there are numerous complexities involved in moving forward in this area, and the way is not absolutely clear. That said, as the researchers note, CMS has adopted three key health equity measures to be integrated into the Hospital Inpatient Quality Reporting Program—as referenced above, they will evaluate hospitals based on commitment to health equity as a strategic priority, etc.; and will require that hospitals report the percentage of adult patients screen for five key HRSNs at the time of admission and the proportion who screen positive for these needs.
Per those three measures, the article’s authors write that “The three new measures may not provide sufficient incentives for hospitals to address HRSNs and reduce health inequities. In future years, CMS could create follow-on measures that evaluate the number of patients who received interventions focused on their HRSNs, stratified by characteristics such as race and ethnicity, or evaluate a hospital’s overall progress toward reducing health inequities affecting marginalized populations, such as inequities driven by structural racism. Unlike larger integrated health care systems, however, safety-net hospitals that disproportionately serve disadvantaged communities may lack the resources to invest in nonreimbursed social interventions. Adoption of equity-centered value-based payment models may increase financial flexibility and stability for hospitals and enable them to provide both health and social care services.” Even so, they note, it’s not clear that HRSN screening alone will reduce health disparities. As they conclude, “Translating measurement into meaningful action will require thoughtful leadership from hospitals in close collaboration with primary care practices, community-based organizations, and payers. Ultimately, hospital actions shouldn’t be viewed as a panacea for achieving health equity, but rather as adjuvants to broader state and federal policies that improve the social conditions that drive health outcomes.”
