Health Law Daily Wrap Up, STRATEGIC PERSPECTIVES: Now is the time for Biden Administration to address drivers of health, (Mar 11, 2021)

By Rebecca Mayo, J.D.

This Strategic Perspective discusses the impact of drivers of health on patient outcomes and health care spending and why the Biden Administration should prioritize drivers of health in policy decisions.

The COVID-19 public health emergency brought attention to the role that drivers of health play in patient outcomes, which many public health experts have sought to address for years. Studies show that medical care accounts for an estimated 20 percent of health outcomes, while 80 percent is attributed to socioeconomic, environmental, and behavioral factors, also known as ‘social determinants of health’ or ‘drivers of health’. Factors such as homelessness, food insecurity, exposure to intimate partner violence, adverse childhood experiences, and racism tend to be linked to poorer health and people with these and other social and economic risk factors have been shown to have worse health outcomes, lower Merit-based Incentive Payment System (MIPS) scores (affecting Medicare payments to clinicians), increased utilizations, and significantly higher annual health care expenditures. This Strategic Perspective discusses how the Biden Administration could improve patient outcomes and reduce health care spending by integrating drivers of health into federal and state health care policies.

Importance of drivers of health

Over the past decade, policymakers and industry leaders have moved away from incentivizing volume and high-cost interventions to a system of linking payment to value. However, a study published in 2017 showed that 24 percent of patients with commercial health insurance still lacked adequate food or housing. A food insecure adult has $1,834 more annual healthcare expenditures and an adult in a food insecure household is 47 percent more likely to be admitted to the hospital, according to Humana’s Food Insecurity Issue Brief. Additionally, there is a 27 percent increase in hypoglycemia admissions during the last week of the month for low-income, diabetic adults due to food budget exhaustion. The Kaiser Family Foundation (KFF) found that there is growing evidence showing that when health care and community-based organizations work together to assure that the most complex patients have social needs including housing, food, and transportation met, their use of expensive health care services such as emergency department visits and hospitalizations often declines. Manatt Health Partner, Melinda Dutton, believes this data supports the idea that "improvement in health care alone will never be enough to improve health." In an interview with Wolters Kluwer, Dutton explained, "we spend about $11 billion per day delivery health care" and when you look at the evidence from KFF and the statistics showing that 80 percent of health outcomes stem from drivers of health, it becomes clear that "[w]e can’t improve health, address health disparities, or bend the cost curve without acknowledging and addressing the factors driving that other 80 percent."

The Biden-Harris Administration announced seven priorities the administration planned to immediately take action on, including controlling the COVID-19 pandemic, advancing racial equity, and protecting and expanding access to quality, affordable health care. According to Dutton, addressing drivers of health is central to achieving these goals. The time to address the drivers of health is now as "[t]he pandemic has pushed our health care system to its limits, crippled the economy, and brought into stark relief longstanding racial inequities." Dutton believes that this perfect storm of health and economic crises has made it clear that in order to improve and protect health, the social, economic, and environmental factors that profoundly impact health need to be addressed. While fully integrating drivers of health into the health care continuum may take time, Dutton noted that "there are many things that federal officials can do today to dramatically accelerate change." Dutton teamed up with Manatt Health Manager, Kyla Ellis and Co-Founders of The Health Initiative, Rocco Perla and Rebecca Onie, to create policy road maps "Investing in Health: A Federal Action Plan" and "Investing in Health: Seven Strategies for States Looking to Buy Health, Not Just Health Care." These policy roadmaps lay out recommendations for actions that can be undertaken to begin integrating drivers of health into health care policies. These reports underline the urgency of taking action due to the impact drivers of health have had on the country’s ability to tackle the COVID-19 pandemic and address racial and economic inequity. Dutton and team indicate that "in the first 100 days of the new administration, CMS should announce its intent to engage states, private payors, providers, consumer groups, community-based organizations and other health care stakeholders in a national partnership to Invest in Health."

Using drivers of health to combat COVID-19

Early COVID-19 statistics showed that minority groups were being infected at higher rates than non-minorities and had an exponentially higher morbidity rate. Current data from the Centers for Disease Control and Prevention (CDC) shows that when compared to white, non-Hispanic persons, black or African American persons are 1.9 times more likely to die from a COVID-19 infection. The data also shows that Hispanic or Latino persons are 2.3 times more likely than a white, non-Hispanic person, and American Indian or Alaska Native persons are 2.4 times more likely to die than a white, non-Hispanic person. These numbers highlight underlying cracks in the health care system, including racial disparities which are often compounded by other drivers of health such as transportation options, availability of community-based resources, and residential segregation that all impact patient outcomes (see Challenges and strategies for addressing disparities in access to health care, October 20, 2020). According to Dutton, combating COVID-19 requires states to address drivers of health. Dutton points out that "[y]ou can’t isolate or quarantine if you lack a home. You can’t stay home if you don’t have family or community supports that will bring you food and medicine. You can’t buy masks or cleaning supplies if your income is already inadequate to cover your water or heating bill. You can’t get a vaccine if you lack transportation to the vaccination site."

To address these health disparities, the federal government can fund efforts to address drivers of health-related barriers to isolation and quarantine and ensure drivers of health are considered during the distribution of the COVID-19 vaccine. The day after being sworn in to office, President Biden signed an Executive Order on Ensuring an Equitable Pandemic Response and Recovery, which created a COVID-19 Health Equity Task Force to collect data to identify barriers to access to equitable care and make policy recommendations. The Biden Administration also provided housing support by extending the COVID-19 Forbearance and Foreclosure Protections for homeowners and the Eviction Moratorium for renters. The Administration also announced an effort to invest $250 million to encourage COVID-19 safety and vaccination among underserved populations. The initiative will target communities at highest risk for health disparities and create a health literacy plan to increase the availability, acceptability and use of COVID-19 public health information and services. Additionally, the U.S. Senate and House of Representatives passed the American Rescue Plan Act of 2021, which is expected to be signed by President Biden on March 12, 2021. The Act would reduce food and housing insecurity by providing funding for emergency rental assistance and housing vouchers, nutritional assistance programs, additional WIC benefits, along with additional child tax credits, among other things. This funding package would reduce the projected poverty rate for 2021 by more than one-third, according to the Urban Institute, with key elements reducing poverty by more than half for children and for people in households experiencing job loss.

Similarly, states can prioritize the use of federal relief funds or implement Medicaid policy changes to provide for support related to drivers of health. These supports could include housing supports, meal delivery, transportation assistance, and any other gaps in social supports that are identified. Dutton pointed to a report from the KFF that found than nearly two-thirds of states surveyed reported implementation, expansion, or reform of a program or initiative to address Medicaid enrollees’ drivers of health in response to COVID-19. For example, Michigan created its own Coronavirus Task Force on Racial Disparities to remove barriers to care and mitigate environmental and infrastructure factors contributing to increased exposure during pandemics resulting in mortality. North Carolina created a COVID-19 Support Services Program to provide assistance with rent, expenses, grocery and medication delivery, transportation, and COVID-19 protection supplies such as masks and hand sanitizer to people who are required to isolate. According to Dutton, states need the funding and flexibility to continue these efforts, however structural changes are needed for a longer term impact.

Integrating drivers of health into payment policy

Longer term structural changes would include things like integrating drivers of health into payment policy for providers and payors, which Dutton believes is foundational to sustainability. In 2018, Congress passed the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act (CHRONIC Care Act) (P.L. 115-870), which allowed Medicare Advantage plans to opt to pay for benefits like healthy meal delivery, transportation to the pharmacy or grocery store, and other services that may promote health but are not strictly medical in nature. A report by The Commonwealth Fund found that in response to the passage of the CHRONIC Care Act, insurers were beginning to offer benefits to address a wide range of social problems including food insecurity and social isolation. However, The Commonwealth Found that some plans were hesitant to begin offering these types of services without knowing how members would react because member satisfaction affects the plan’s star ratings and help determine whether they earn rebate dollars that could be used to fund supplemental services. There were also concerns about funding the supplemental benefits whether Medicare Advantage plans would use risk adjustment to increase payment but not use the extra dollars to target areas of greatest need.

While there has been increased flexibility in Medicare Advantage plans and states are increasingly leveraging "in lieu of services" to allow nontraditional interventions to be built into their Medicaid managed care rates, Dutton notes that this has still only spurred modest but growing adoption of drivers of health interventions and these efforts are not yet at scale. Part of this, according to Dutton, is due to the fact that "we are still learning about what works for whom and how to best bring those strategies to scale." However, there is a failure to "consider both the differential in the cost of providing care for those experiencing social or economic deprivation, and to reimburse for the range of interventions that would most efficiently address their health needs." According to a study published in the Journal of the American Medical Association, providing a medically tailored meal delivery program for medically and socially complex adults was associated with cutting inpatient admission in half. Dutton asserts that even with knowledge that a program like the one in the study would be effective, plans are unlikely to be able to sustain that program unless it is built into the plan’s reimbursement.

In the Federal Action Plan, Dutton and her team make recommendations such as developing a Medicare Advantage risk adjustment model that incorporates patient-level drivers of health factors into the Hierarchical Condition Category score. Further, under current guidance it is unclear whether drivers of health interventions qualify as medical expenses in the medical loss ratio (MLR) calculation as quality improvement activities or whether they are considered administrative expenses. Therefore, the Federal Action Plan recommends providing guidance clarifying that drivers of health interventions that improve health may be counted as quality improvement activities. Additionally, value-based payment (VBP) initiatives and rewards could be designed to reimburse providers for improving outcomes and reducing costs, or to promote drivers of health interventions that have been proven to improve health outcomes. According to Dutton, integrating drivers of health "into risk scoring and risk adjustment, and recognizing drivers of health-related investments in MLR calculations, are prerequisites to a sustainable business case for drivers of health investments.

Creating standards for drivers of health

A 2019 survey by the eHealth Initiative and Foundation found that social determinants of health were the most challenging data type to exchange. This was due to a lack of consensus on standards for capturing and representing drivers of health data, which created barriers to collection and use, as well as navigation of legal parameters for cross-sector information sharing. The HHS Office of the National Coordinator for Health Information Technology (ONC) currently has a project, Advancing SDoH Health IT Enabled Tools and Data Interoperability: eCDS and Data Tagging which aims to advance the interoperability of drivers of health data by supporting stakeholder efforts to conduct data tagging and by assessing the feasibility of developing electronic clinical decision support (eCDS) that incorporates drivers of health data. According to the ONC, two important existing and emerging tools for advancing the use of drivers of health data in clinical and community settings are data tagging and eCDS. eCDS can enable the integration of drivers of health decision-making data into clinical workflows, as supported by specialty practice guidelines, making it more likely that drivers of health information will be utilized as a part of care delivery.

Developing and using common standards for measuring needs and outcomes is one of the top three structural changes needed to bring drivers of health interventions to scale, according to Dutton, and "[w]ithout federal action, payers and providers will continue to develop local codes and local solutions, which could stymy future, collective progress in responding to key drivers of health indicators." The Federal Action Plan recommends establishing comprehensive nationwide standards for drivers of health data, collection and measurement focused on both process and outcome measures. Dutton notes that "[w]e need standardized methods for DOH data collection, including common screening tools and data formats, a shared understanding of how we can effectively incorporate these new data into our care management processes to target interventions (e.g., risk stratification), and a common legal and regulatory framework to allow this data to be collected and exchanged to promote health, while protecting individual privacy."

Once data collection and measurement for drivers of health have been standardized, CMS and stakeholders will be able to better assess the impact of drivers of health and the efficacy of interventions. The Federal Action Plan notes that some drivers of health interventions have a longer time horizon such as investments in children. Half of children have publicly funded health insurance and research shows they are both particularly vulnerable to drivers of health particularly responsive to interventions. However, investments in children often take a longer time to show their full value, and cost savings often accrue beyond the health plan or payor making the investment. Therefore, new models are needed to ensure that this does not disincentivize investment. Over time, as more data is collected CMS will be able to expand the number and diversity of domains and interventions and even address the compounding effects of certain drivers.

Future outlook

The Biden Administration has made clear that health care and racial equity are top priorities for the administration to address. Dutton notes that "people of color experience health disparities even after controlling for economic and environmental factors. Discrimination and institutional racism are compounded by, but also exist independent of what is commonly thought of as drivers of health." This means that these two goals of the Biden Administration will need to work in tandem in order to achieve health equity. Because people of color are disproportionately impacted by the social and economic factors that affect health outcomes, evidenced by the disproportionate impact of COVID-19 on communities of color, which, according to Dutton, has led many to predict that the gap is likely to widen in the aftermath of COVID-19 without dedicated intervention. Though Dutton anticipates that "the Biden team will see this connection and prioritize addressing drivers of health as part of their larger efforts to promote health equity."

Companies: Melinda Dutton (Manatt Health)

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