CMS’ proposed Universal Foundation can be starting point to treat social drivers of health

A new “Universal Foundation” for measuring patient health outcomes can be the base for addressing social circumstances that affect health and wellness before patients ever get to the doctor’s office.

Leaders within the U.S. Centers for Medicare & Medicaid Services have proposed the new Universal Foundation, a core set of quality measures that align across programs currently using their own criteria to assess physicians, clinicians, and health care settings.

That federal leadership can become a meaningful – even historic – step forward in changing how doctors, patients, and payers address drivers of health (DOH), according to The Physicians Foundation. Also called social drivers or social determinants of health (SDOH), those factors can range from food insecurity to transportation or utility issues, to interpersonal safety.

Gary Price, MD, MBA
_{The Physicians Foundation}

“That covers a pretty broad area,” said Physicians Foundation President Gary Price, MD, MBA. “These are things that aren't necessarily part of what we would think of as traditional medical care, but they can have a huge influence on both the cost and the outcomes of medical care.”

Price spoke with Medical Economics about the proposed Universal Foundation and how physicians may engage patients to address DOH. This transcript has been edited for length and clarity.

Medical Economics (ME): I'd like to make the connection with the drivers of health identified by The Physicians Foundation and the U.S. Centers for Medicare & Medicaid Services’ proposed “Universal Foundation” as a baseline for measuring adult and pediatric health. Can you talk about the Universal Foundation and what that means for drivers of health?

Gary Price, MD, MBA: This concept of a Universal Foundation of measures I think is a very important step in making sure that measures as we go forward are aligned with each other. That different organizations – for instance, hospitals, clinics, physician's offices, emergency rooms – that we're all using the same language, if you will, with a measure so that the data can really be looked at and we can get meaningful conclusions from that.

Beyond that technical aspect, I think this is a sea change in approach to the quality measures in that CMS has acknowledged that they need to be built upon a solid foundation. The CMS announcement about them stress the fact that they expect them to be improved and developed and built upon as time goes by. They critically acknowledge that in adopting and implementing them, they need to be conscious of the efficiency of the work that everyone on the frontlines of health care is doing and making sure that the measures, as they are implemented and designed, contribute to that efficiency, and don't actually work against it. In the past, because of the fact that measures weren't aligned in many different ways, there was a great deal of inefficiency put into the system.

Going beyond that, the Foundation's particularly pleased to see that the two drivers of health measures that the Foundation introduced over two years ago are part of the 23 fundamental building blocks. This is perhaps even a more important historical turning point for health care policy in our country, in that for the first time we've incorporated measures that include drivers-of-health-factors into what is the largest health insurance system in our country, the Medicare and Medicaid systems. Previous to this point, there have been no quality measures at all that referenced drivers of health measures whatsoever. So this is a real inflection point where we've acknowledged in governmental policy that these factors are important, we need to measure them, and we need to address them to improve health care outcomes and costs.

ME: What are those two drivers?

Price: Those two measures are very simple, what we regard as a beginning. We expect them to be improved upon and expanded. But the measures themselves as in the CMS rule that was published last August. The first measure is simply the number of beneficiaries 18 years of age or older, who were screened for food insecurity, housing instability, transportation issues, utility issues, and issues concerning interpersonal safety. The second measure asks that it'd be reported a percentage of positive recipient recipients. In other words, the percentage of those 18 years or older who were screened, who actually reported a positive screening with one of those issues.

ME: On a day-to-day basis, in the office, in the practices, in the health systems, physicians and clinicians are stretched as thin as can be. Even if they ask their patients about some of those drivers of health, what are some practical ways that physicians might be able to help change them?

Price: Just simply measuring them as the first step and beginning to address that. Having said that, the Foundation has funded an organization called Health Leads and so it was one of the first to begin to look at ways that practical tools and strategies could be used at the frontlines of care to remove that burden from the physicians themselves. And I think the promise is that as we begin to measure and more scientifically assess these and also test strategies on the frontlines of care that we can figure out efficient and effective ways to connect patients with resources for these things that don't require a lot of time on the part of the physician, but also that we know actually work and that's why these just beginning measures are so important. Without the data to understand what the need is, without the data to understand how well we can solve that need with interventions, we really can't do anything.

It is critically important that as they're implemented, that we do this in an efficient way. And that involves a number of very simple starting strategies. Number one, make sure that we only need to collect the data once, that once it's been assessed, it doesn't have to be asked of the patient over and over again. That's step one.

Number two, that we ask the questions in a way that patients are willing to answer them, frankly.

Number three, if we're going to ask the question, we do need to have a way to follow up on that and to begin to address it.

And fourth, I think it's really important that we make sure that how we ask about these questions, how we code them within our health care record systems is consistent across all the different platforms that health care is delivered in, so that we really have a meaningful way of looking at the entire picture that that is accurate, and can help us get to the real answers to these questions that you bring up.

ME: There are existing social services and charitable organizations that may be able to help patients who need help. How important is that communication or connection between physicians and those existing resources that could help patients who are facing difficulties with drivers of health?

Price: Another critical question and part of the solution because there is a huge gap between what's going on in what we think of as traditional health care and connections to those kinds of community resources. In that survey I mentioned physicians last year, physicians did have a number of strategies that 80% or more of them, agreed were going to be necessary going forward as far as drivers of health are concerned. And one of them was an investment in community resources. But the second was increasing the efficiency, the availability of being able to make a referral from a health care point of care to those agencies right now. We need to improve the connection, that communication, if you will, and follow through on those to make sure our patients are getting the resources they need.

ME: What would you like to say to primary care physicians dealing with drivers of health? What should they know? Are there additional resources you would recommend, or how should they approach this topic?

Price: I think drivers of health is a really major factor of many factors that are really creating an inordinate amount of stress for our primary care physicians to help them with the outcomes that they need to get for their patients, the inequities that they witness every day, reducing costs and the care they provide. We need to be able to help them identify drivers of health needs, but also connect them with the resources that can help their patients get better health care outcomes and reduce those overall costs. And at the primary care level, there's really a tremendous problem with time that's not available, some of it because it's wasted. Some of it because we haven't figured out and a more efficient way to do things. Some of it because our primary care physicians are asked to do things that really aren't meaningful and don't help their patients’ care. So I think identifying and addressing drivers of health is a big part of helping take some of the burden off of them and but to accomplish their basic goal and that's to keep their patients healthy and to keep their health care costs down.

ME: Many Americans still rely on other forms of health insurance to cover their costs. With the leadership of CMS, how important is that in terms of influencing some of those other health insurance companies?

Price: It's critically important. We know that the private health insurance industry usually follows the lead of CMS, particularly in areas that involve financial incentives, quality measures, reimbursement issues, investments in communities. So I think it's very important, the precedent that CMS has set with these measures. It really does signal how our whole entire health care system will be approaching health care and adds, so importantly, this element of drivers of health. The attention also highlights the fact that these drivers of health really do have a tremendous impact on outcomes and cost. And that's important to anyone who's underwriting health care, so that it can show to them where investments might give a high return and actually improve outcomes and decrease costs. That's the argument you need to make to someone who's financing health care.