Accountability Key for Better Health for At-Risk Groups

— Report says providers also must understand population health needs

MedpageToday

If healthcare for at-risk groups within Medicare is to be improved, providers need to promote the idea and hold themselves accountable for the care they give, according to a report from the National Academies of Sciences, Engineering, and Medicine.

"Effectively reducing health inequities will likely require an organization to accept accountability for its population health outcomes," noted the authors of the report, entitled "Systems Practices for the Care of Socially At-Risk Populations." Because population health is defined at the community level and is not restricted to an enrolled or patient population, organizations are accountable for community-level population health outcomes, not just the outcomes of their patient population."

The report defined at-risk populations as "individuals with social risk factors for poor health outcomes such as low socioeconomic position, social isolation, residing in a disadvantaged neighborhood, identifying as a racial or an ethnic minority, having a non-normative gender or sexual orientation, and having limited health literacy."

The authors listed six ways for providers to improve care for this group:

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

Getting good care for this population is not impossible, according to the report, which was written by a committee chaired by Donald Steinwachs, PhD, of Johns Hopkins University in Baltimore. "It is possible to deliver high-quality care to these populations and the committee outlined certain systems practices that could be instrumental in achieving that goal," the authors wrote. "This report [shows] that socially at-risk populations do not need to experience low-quality care and bad health care outcomes. With adequate resources, providers can feasibly respond to incentives to deliver high-quality and good value care to socially at-risk populations."

For each of the six concepts, the authors provide examples of places that are working to accomplish them. For instance, HealthPartners, a nonprofit healthcare organization operating in four Midwestern states, worked on the accountability piece by compiling a "disparities scorecard" which gives quality and patient experience information organization by subpopulation, and also provides local-level population data to clinic managers. Clinic leaders are required to write out goals for reducing disparities, and their payment incentives include disparities reduction goals.

Using this program, HealthPartners cut race and ethnicity disparities in mammography screening by nearly half from 2007 to 2010, and payer disparities (publicly compared to privately insured women) by nearly one-fifth during the same period, the report noted.

Although the report did contain examples, it also showed that the research in this area is not as advanced as it could be, Michael Chernew, MD, of Harvard University in Cambridge, Mass., who was one of the reviewers for the report, told MedPage Today in a phone interview. “The level of evaluation of many of those examples, while [the results are] suggestive, the evidence base to understand what the impact was, how generalizable it is, all of those questions, is really weaker than we would like it to be,” he said.

The report can also help people understand that “the health outcomes Americans achieve are related to things outside the healthcare system,” such as the availability of fresh produce, he continued. “We have a broader idea now of how the health system interacts with individuals to improve health, and the ability of the healthcare system to do that depends on contextual factors, including a lot of outside support.”

This report is the second in a series of five reports that looks at social risk factors affecting health outcomes for Medicare beneficiaries, and how these factors can be taken into account when designing Medicare payment programs. David Howard, PhD, a professor of health policy and management at Emory University in Atlanta, noted in an email that "As Medicare moves to reimbursement schemes that reward providers for meeting quality and cost targets, it is important to consider whether these schemes unfairly penalize providers that take care of patients from disadvantaged groups."

While this particular report doesn't look at that question -- instead, it will be the subject of the third report -- it "suggests that providers that take care of disadvantaged populations are not predestined to have lower quality and higher costs," Howard wrote. "Based on this conclusion, I would guess the third report will recommend against having Medicare adjust cost and quality measures for the socioeconomic status of each providers' patients," although he noted that the current report specifically says it's not foreshadowing what the next report will conclude.