Health insurers often pay health plans to manage the care of their members. Good care can help prevent emergencies, such as avoidable trips to a hospital emergency department (ED). Medically complex patients, such as those with behavioral health problems or substance use disorders, tend to have a lot of ED visits. Social determinants of health (SDH) also affect outcomes for complex patients.
MassHealth, the Massachusetts Medicaid program, launched its Accountable Care Organization (ACO) program in 2018. Among its goals are to provide better coordinated care and reduce unnecessary care, including avoidable ED visits. But what does all of this mean, and how are these issues interrelated? A recent study published in Medical Care by a team at the University of Massachusetts Medical School (UMMS) examines the intersection of these hot topics.
The study looks at ED use by adult MassHealth ACO members with serious mental illness (SMI) or substance use disorders (SUD). The authors describe the development of a risk-adjusted quality measure designed to encourage reductions in ED use. The UMMS study is part of MassHealth’s efforts to measure and reward quality in its ACO program.
A person’s age, sex, and health history form the basis of their medical risk. Similarly, a person’s social risk, by definition, derives from the social determinants of health (described below). Risk-adjusting the measure means that plans are accountable for levels of ED use adjusted for the medical and social risk of their members.
Social Determinants of Health
The US Centers for Disease Control and Prevention and the Department of Health and Human Services define the social determinants of health as “the conditions in the environments where 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.” SDH domains include economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. SDH, among other factors, drive health inequity.
A recent post in this blog discussed the role of data science in the development of a new social risk measure. Several existing measures, such as the Area Deprivation Index, the Social Deprivation Index, and the Social Vulnerability Index are compared. In the UMass study, the researchers developed their own measure, called the Neighborhood Stress Score (NSS). The NSS is based on 7 census-block-group-level variables indicating economic stress. It remains an open question what to include in such a measure.
A 2017 article by the UMMS team and others included SDH in MassHealth payment formulas to address health inequities. In that article, the authors concluded that a “payment formula that accounts for medical problems but ignores social risk can underpay for vulnerable populations, potentially exacerbating inequality. MassHealth’s social determinants of health payment model uses existing Medicaid data and reproducible methods to support care for vulnerable members and improve payment equity.”
Accountable Care Organizations
Accountable Care Organizations (ACOs) are medical practices, hospitals, and other health systems that work together to provide coordinated care to their patients. Effective care coordination is important because it ensures that patients, especially those with chronic conditions, receive appropriate care when needed. Furthermore, care coordination can help to avoid unnecessary services and medical errors. When ACOs successfully deliver quality care and reduce costs, they can share in the savings achieved.
In 2018, MassHealth launched its ACO program, with 17 ACOs serving over 850,000 people. Its goals are to:
- Improve quality and member experience,
- Integrate the full spectrum of care, including medical care, behavioral health, and long term services and supports (LTSS),
- Provide clinical and community-based support for populations with behavioral health and long term health care needs,
- Shift incentives to hold providers accountable for quality and total cost of care for a population of patients,
- Invest in primary care and community workforce development,
- Allow for innovative ways of addressing social determinants of health, and
- Expand access to substance use disorder treatment, including treatment for co-occurring disorders.
Emergency Department Visits
Emergency department use in the US is associated with a number of characteristics. These include chronic medical conditions, multi-morbidity, low income, work limitations, public insurance or lack of insurance, and poor mental health. Mean ED use in the US population is only about 1 visit per person every 2 to 3 years. However, patients with greater medical and social problems use EDs much more frequently. The UMMS study population, for example, averaged 1.77 visits per person per year.
ED visits are expensive, may disrupt continuity of care, and are potentially avoidable with improved patient management. For these reasons, lower ED use is considered a quality indicator. Pay-for-performance programs commonly use quality measures to incentivize health systems to reduce ED utilization. However, without risk adjustment, ACOs that enroll complex patients may receive penalties for higher than average ED use. Similarly, without risk adjustment, ACOs with less complex members may receive rewards for lower than average ED use. This can occur even though low ED use may be due more to whom an ACO enrolls, rather than how well it cares for its patients.
Better patient management should help prevent avoidable ED visits. Such visits may occur due to poor access to—or substandard—routine care. According to the UMMS team, “Better patient management can reduce ED use. Performance measures should reward plans for reducing utilization by predictably high-use patients, rather than rewarding plans that shun them.” In 2019, a related paper observed that “…access to primary care (through insurance) should reduce emergency department (ED) visits for primary care sensitive (PCS) conditions.”
MassHealth ED Visit Quality Measure
The MassHealth ED use measure incentivizes ACOs to reduce ED use for adult members with behavioral health disorders. This population includes adults ages 18-64, with diagnoses of SMI and/or SUD. The UMMS team developed three models to predict ED use in the study population. The models considered: (1) age and sex, (2) age and sex plus medical risk, and (3) age and sex plus medical and social risk. The study predicted ED use rates using regression modeling, comparing accuracy overall and for vulnerable populations.
Among nearly 150,000 MassHealth members who met the study criteria, those diagnosed with both SMI and SUD had 77% higher ED use. In comparison, members with housing problems had 50% higher use. Finally, members living in the highest-stress neighborhoods had 18% higher ED use. SDH modeling predicted best for these high-use populations and was most accurate for plans with complex patients. The study concludes that “[t]o set appropriate benchmarks for comparing health plans, quality measures for ED visits should be adjusted for both medical and social risks.”
Health care quality measures provide a mechanism to assess and reward or penalize health plan and provider performance. However, in addition to care processes, patient characteristics also contribute to outcomes. To incentivize better care for all members, plan managers should benchmark quality measures to the expected outcomes of the populations they serve. Social determinants of health are a crucial part of the benchmarking process.
In sum, complex patients, such as those with behavioral health disorders, unstable housing, or living in high-stress neighborhoods, can be expected to have more ED visits. ACOs and other health plans that care for them should not be penalized when they do.
Thank you to my co-authors on the UMMS study, especially lead author Eric Mick and senior author Arlene Ash, for the opportunity to represent our work and for guidance in preparing this post.
Franny Eanet
Interesting article, but not sure why the author did not mention who manages the complex patients in the article. There are professionals who work in hospitals, managed care companies and other entry points of the healthcare system to coordinate care, transitions patients from one setting to another and educate and empower patients and their families to understand their diagnosis and their plan of care and to address barriers that often sidetrack them as mentioned in the article. These professionals are known by different names depending on the organizations they work but usually called case managers, care managers, care coordination, transition of care nurses and or social workers. They are professionals from various disciplines and have the skills and expertise to work with the broad healthcare team to help patients who are complex or impacted by Social Determinants of Health. The Case Management Society of America is the professional organization for those in the practice of case management. To learn more, visit http://www.cmsa.org/sop to review the Standards of Practice of the practice.