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2023 Providers are Responsible for Social Determinants of Health Quality Measures

New social determinants of health (SDOH) quality measures will be required by hospitals, health plans, and multi-payer federal and state programs.

Research shows that social determinants can be more important than health care or lifestyle choices in influencing health. Numerous studies suggest that SDOH account for between 30-55% of health outcomes. We explain the quality measures across providers and stakeholders.

Hospitals: New SDOH Quality Measure: Starts 2023

CMS’s new SDOH quality measures was published in the 2023 Medicare Hospital Inpatient Prospective Payment System rule, released Aug. 1. Hospitals will be required to report what portion of their population is screened for various SDOH and how many screen positive in each category.

Hospitals will capture screening and identification of patient-level, health-related social needs—such as food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. By screening for and identifying such unmet needs, hospitals will be in a better position to serve patients holistically by addressing and monitoring what are often key contributors to poor physical and mental health outcomes.

Health Plans: 2023 Social Determinants of Health Quality Measure Begin

The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of U.S. health plans to measure performance on important dimensions of care and service.

Because so many health plans use HEDIS and because the measures are so specifically defined, HEDIS can be used to make comparisons among plans. To ensure that HEDIS stays current, the National Committee for Quality Assurance (NCQA) has established a process to evolve the measurement set each year through its Committee on Performance Measurement. HEDIS is one of health care’s most widely used performance improvement tools. 191 million people are enrolled in plans that report HEDIS results.

The NCQA announced new and revised quality measures for health plans in the Healthcare Effectiveness Data and Information Set (HEDIS) for measurement year 2023.

One of those measures is Social Need Screening and Intervention (SNS-E). The goal of this measure is to identify and address members’ social determinants of health needs and to encourage health plans to assess and address the food, housing and transportation needs of their patient populations. The screening looks at food, housing, and transportation needs. This measure helps health plans identify specific needs and connect members with resources necessary to address unmet social needs.
“We can’t address needs that we don’t know exist,” Rachel Harrington, PhD, a research scientist at NCQA, said in an interview. “Having a metric that identifies social needs provides information that is necessary to begin to address the barriers to pursuing health for patients and individuals.” The movement toward value-based care has brought those social factors to the center of the conversation.

“Z” Codes: Is Your Organization Asking Hospitals, SNFs, and Physicians for “Z” Codes at Discharge?

What are “Z” Codes?

Health care providers use Z codes to capture standardized data on social determinants of health for 525,987 Medicare fee-for-service beneficiaries in 2019, according to a report by the Centers for Medicare & Medicaid Services

  • Z codes are a tool for identifying a range of issues related – but not limited – to education and literacy, employment, housing, ability to obtain adequate amounts of food or safe drinking water, and occupational exposure to toxic agents, dust, or radiation.
  • Z codes can be used in any health setting (e.g., doctor’s office, hospital, skilled nursing facility (SNF) and by any provider (e.g., physician, nurse practitioner).
    Z codes are a set of ICD-10-CM codes used to report social, economic, and environmental determinants known to affect health and health-related outcomes. Z codes comprehensively identify non-medical factors affecting health and track progress toward addressing them.

A report from CMS “Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017,” indicates among the 33.1 million continuously enrolled Medicare FFS beneficiaries in 2019, 1.59% had claims with Z codes, as compared to 1.31% in 2016.

Key Findings: The 5 Most Utilized Z Codes

  1. Z59.0 Homelessness
  2. Z63.4 Disappearance and death of family member
  3. Z60.2 Problems related to living alone
  4. Z59.3 Problems related to living in a residential institution
  5. Z63.0 Problems in relationship with spouse or partner

The Centers for Medicare & Medicaid Services (CMS) reported that Z codes have been captured for just 1.6% of Medicare beneficiaries. they represent a codified way to document unmet needs.

For more insight into which patient populations are using Z codes the most, read “Patient Discharge: Is Your Organization Asking Hospitals, SNFs, and Physicians for “Z” Codes?”

Medicare Managed Care Organizations: Federal and State Regulations For Screening and Technology Usage

Federal regulations require MCOs to conduct an initial screening of each enrollee’s needs within 90 days of enrollment. These regulations provide states broad flexibility to develop MCO screening requirements.

States are increasingly requiring MCOs to incorporate methods to identify SDOH needs in screenings, covering areas such as housing, employment status, food insecurity, physical safety and transportation needs. Additionally, some states are contractually requiring MCOs to either encourage or require their provider networks to incorporate SDOH needs screening into their practices. Louisiana and Ohio require MCOs to reimburse providers for SDOH screening and submitting applicable diagnosis codes (Z codes) on claims

Main trends in SDOH state requirements:

  • Many states are requiring MCOs or provider networks to screen enrollees for SDOH needs.
  • States are increasingly requiring MCO care management programs to incorporate SDOH, to coordinate with community-based organizations and to ensure referrals to social services and supports.
  • Recent RFPs have included requirements that MCOs incorporate SDOH into their quality assessment and performance improvement (QAPI) programs and that MCOs provide SDOH training for staff.

Some states are also requiring MCOs to leverage technology in their SDOH screening efforts. For example, in Arizona, MCOs are required to utilize a Statewide Closed-Loop Referral System (CLRS) to refer enrollees to community-based organizations (CBOs) addressing SDOH. Additionally, Hawaii requires the MCOs’ information systems to support integration and facilitate predictive analytics to identify enrollees likely to benefit from special program services, including SDOH supports.

For more insights on Medicare managed care social determinants, read “Nine Payer and State Medicaid Managed Care Investments in Social Determinants.”

24% of Hospitals and 15% of Physician Practice Screen for Social Determinants

A 2019 cross-sectional survey in the New England Journal of Medicine, examined the screening of social needs by physician practices and hospitals.

  • Question: What types of physician practices and hospitals self-report screening patients for food, housing, transportation, utilities, and interpersonal violence needs?
  • Findings: In the study of US hospitals and physician practices, approximately 24% of hospitals and 16% of physician practices reported screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. Federally qualified health centers and physician practices participating in bundled payments, primary care improvement models, and Medicaid accountable care organizations screened more than other hospitals, and academic medical centers screened more than other practices.
  • Meaning: This study’s findings suggest that most US physician practices and hospitals do not report screening patients for key social needs, and it appears that practices serving more economically disadvantaged populations report screening at higher rates.

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