FutureFocus October 24, 2018: Medicare Advantage and the IMPACT Act: Social Risk Factors Best Practice

Lisa Remington

This week’s FutureFocus insight is a window into your future. All payers are focusing on social risk factors. Strong market signals are brewing.  Social risk factors become a readmission penalty in 2019, the IMPACT Act is required to conduct studies on socioeconomic status, and Medicare Advantage Plans are incorporating supplemental benefits to address social determinants. Social risk factors will become a common quality measure across the continuum. Get a head of the curve to learn what this means for your organization.

Lisa Remington, President, Remington Health Strategy Group

By: Lisa Remington, President Remington Health Strategy Group, Publisher, The Remington Report

How are providers and health plans serving Medicare beneficiaries working to improve health outcomes for beneficiaries, especially those with social risk factors?

Did you know: Section 2(d) of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 calls for the Secretary of Health and Human Services (HHS), acting through the Assistant Secretary for Planning and Evaluation (ASPE), to conduct a study evaluating the effect of individuals’ socioeconomic status (SES) on quality measures and measures of resource use under the Medicare program.

The Department of Health and Human Services has issued a request for information on how health care providers and health plans are working to improve care for Medicare patients with social risk factors. Comments are due by Nov. 16. The responses to the RFI will be used in a report required by the Improving Medicare Post-Acute Care Transformation Act of 2014 on issues related to social risk in Medicare's value-based payment programs. The report will be completed by October 2019.

Why is this important to your organization?

  1. Beginning in 2019, social risk factors and hospital readmission penalties: The 21st Century Cures Act required that CMS develop a methodology for the Hospital Readmissions Reduction Program (HRRP) for the dual-eligible. These beneficiaries are eligible for both Medicare and Medicaid. CMS will incorporate the socioeconomic status of dual-eligible patients toward readmission penalties.
  1. In April, CMS issued a final rule giving Medicare Advantage plans additional flexibility in determining supplemental benefits to include items and services to address social determinants of health (SDOH).
  1. More than 80 percent of payors are integrating social determinants of health (SDOH) into their benefit program according to a Pulse survey earlier this year. Organizations are taking steps to leverage community programs and resources, integrate medical data with financial census and geographical data, and training doctors to identify social indicators.
  1. In 2017, 19 states required Medicaid MCOs to screen beneficiaries for social needs and/or provide enrollees with referrals to social services and six states required MCOs to provide care coordination services to enrollees moving out of incarceration, with additional states planning to implement such requirements in 2018.

HHS and Social Risk Factors

HHS is interested in understanding services targeted to Medicare beneficiaries with social risk factors. The 2016 Report to Congress found that providers that disproportionately cared for beneficiaries with social risk factors tended to perform worse than their peers on quality measures. However, in every setting, be it hospital, health plan, ACO, physician group, or facility, there were some providers that served a high proportion of beneficiaries with social risk factors who achieved high levels of performance.

HHS is interested in how plans and providers serving Medicare beneficiaries:

  • Identify beneficiaries with social risk factors
  • Approaches plans and providers have used to address the needs of beneficiaries with social risk factors
  • Evidence regarding the impact of these approaches on quality outcomes and the total cost of care
  • Disentangle beneficiaries’ social and medical risks and address each

There is growing recognition that social risk factors – such as income, education, race and ethnicity, employment, housing, food, community resources, and social support – play a major role in health. Despite ongoing efforts, significant gaps remain in health and in life expectancy based on income, race, ethnicity, and community environment.

At the same time, the health care system is increasingly moving towards higher levels of provider accountability for the quality, outcomes, and costs of care. Value-based or alternative payment models, which tie payment to the quality and efficiency of health care delivered, are in place in nearly all Medicare settings, including in hospitals, outpatient settings, and post-acute facilities. In many ways, beneficiaries with social risk factors may benefit the most from value-based purchasing programs and other delivery system reform efforts, since improved care coordination and provider cooperation will be of the highest utility to the most complex beneficiaries with the most care needs.

In the 2018 Medicare payment rules, CMS solicited comments on when and how the Medicare program should account for social risk in quality measures and programs.

Best Practices

The ASPE asked the NASEM to identify best practices of high-performing hospitals, health plans, and other providers that serve disproportionately higher shares of socioeconomically disadvantaged populations and compare those best practices to practices of low-performing providers serving similar patient populations.

The NASEM determined that the following six practices show promise for achieving high levels of performance for beneficiaries with social risk factors:

  1. Commitment to health equity: Value and promote health equity and hold yourself accountable
  2. Data and measurement: Understand your population’s health, risk factors, and patterns of care
  3. Comprehensive needs assessment: Identify, anticipate, and respond to clinical and social needs
  4. Collaborative partnerships: Collaborate within and across provider teams and service sectors to deliver care
  5. Care continuity: Plan care and care transitions to prepare for patients’ changing clinical and social needs
  6. Engaging patients in their care: Design individualized care to promote the health of individuals in the community setting

Medicare Advantage Plans

ASPE also contracted with RAND to conduct interviews and case studies with Medicare Advantage (MA) plans to understand how the plans address dually enrolled beneficiaries social and health needs.

High-performing, high-dual and special needs plans (SNP) were found to implement multi-pronged approaches and strategies. Through this work, we developed a taxonomy for MA plans addressing social needs that includes strategies and interventions that focus on:

  1. Needs identification and targeting
  2. Care management and coordination
  3. Directly addressing social needs
  4. Integration of Medicare and Medicaid

HHS Request for Information (RFI)

HHS is requesting information on how providers and health plans are implementing these approaches and principles for Medicare beneficiaries with social risk factors. HHS is also interested in approaches beyond the NASEM principles and health plan taxonomy that work to improve care for Medicare beneficiaries with social risk factors.

  • Are social risk data being used to target services or provide outreach? If so, how? How are beneficiaries with social risk factors identified?
  • Are there especially promising strategies for improving care for patients with social risk?
  • How are costs for targeting and providing those services evaluated? What are the additional costs to target services, such as case management, and to provide additional services (e.g., transportation)? What is the return on investment in improved outcomes or reduced healthcare costs?
  • What are the best practices to refer beneficiaries to social service organizations that can address social risk factors?
  • What lessons have been learned about providing care for patients with social risk factors?
  • What are barriers to tailoring services to patients with social risk factors? How can barriers be overcome?
  • For patients with social risk factors, how does patients’ disability, functional status, or frailty affect the provision of services?


The first component of the required work, a 2016 Report to Congress, focused on socioeconomic information currently available in Medicare data.

As part of the second Report to Congress, HHS is requesting information on how providers and health plans capture beneficiaries’ social risk.

The Medicare program captures limited information on beneficiary social risk, but there is potential for additional information to be collected by health plans or providers at the point of care.

In particular, the NASEM identified electronic health records (EHRs) as a potential source of social risk data. In earlier work, a separate NASEM committee recommended that certain social and behavioral health domains be collected in EHRs. ASPE also contracted with NORC to conduct a qualitative study of EHR vendors’ incorporation of social determinants of health in EHRs.

Among the 6 vendors interviewed, all were incorporating social determinants of health into their systems in response to client demand, although the type of product varied greatly across the vendors. HHS is requesting information on how providers and health plans are collecting and using data on Medicare beneficiaries’ social risk factors:

  • Which social risk factors are most important to capture?
  • Do you routinely and systematically collect data about social risk? Who collects this data? When is it collected? Is it collected only once or multiple times for a beneficiary? Is it collected consistently across populations (i.e. Medicare beneficiaries, Medicaid beneficiaries, patients receiving specific services, etc.)? What are the burdens of this data collection on plans, providers, and beneficiaries?
  • Would standardized data elements for EHRs help you to collect social risk data? If so, how could these data elements be standardized?
  • What are barriers to collecting data about social risk? How can these barriers be overcome?
  • What do you see as promising future opportunities for improving data collection? For using existing or future data to tailor services?

Submitting Comments

Comments will be received until November 16, 2018.

Submit electronic comments via email to ASPEImpactStudy@hhs.gov

Note to commenters

This RFI is issued solely for information and planning purposes; it does not constitute a Request for Proposal, applications, proposal abstracts, or quotations. This RFI does not commit the Government to contract for any supplies or services or make a grant or cooperative agreement award. Further, HHS is not seeking proposals through this RFI and will not accept unsolicited proposals. Responders are advised that the U.S. Government will not pay for any information or administrative costs incurred in response to this RFI; all costs associated with responding to this RFI will be solely at the interested party’s expense. Not responding to this RFI does not preclude participation in any future procurement or program, if conducted. It is the responsibility of the potential responders to monitor this RFI announcement for additional information pertaining to this request.

Please note that HHS will not respond to questions about the policy issues raised in this RFI. HHS may or may not choose to contact individual responders. Such communications would only serve to further clarify written responses. Contractor support personnel may be used to review RFI responses. Responses to this RFI are not offers and cannot be accepted by the Government to form a binding contract. Information obtained as a result of this RFI may be used by the Government for program planning on a non‐attribution basis. Respondents should not include any information that might be considered proprietary or confidential. This RFI should not be construed as a commitment or authorization to incur costs for which payment would be required or sought. All submissions become Government property and will not be returned. HHS may publicly post the comments received, or a summary thereof.

For more insight: Five Trends Focused On Social Determinants