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Adjustments to payment models are beginning to take social determinants into account.
Where people work, live and play can greatly affect their health and the quality of healthcare they receive. Research already has shown that these social determinants of health (SDOH) are potent. Now researchers are digging deeper and learning how SDOH affect diseases, including risk for certain cancers and their outcomes after treatment, says Katherine Reeder-Hayes, M.D., M.B.A., M.S., chair of the American Society of Clinical Oncology’s Health Equity Committee. The considerable differences between poor and wealthier patients, as well as between Black and White patients, can often be traced to SDOH, says Reeder-Hayes, who is also an associate professor and chief of breast oncology at the University of North Carolina-Chapel Hill School of Medicine.
Here’s a closer look at how SDOH affect cancer rates in certain populations, how these disparities influence cost and payment of cancer care, and how new payment models are better addressing SDOH.
Incidence, mortality differences
According to American Cancer Society research, Black males have the highest cancer incidence (549 per 100,000) and death (240) rates of any group identified by race and ethnicity and by gender. Black females have higher cancer death rates than non-Hispanic white females despite a lower incidence rate.
Comorbidities such as diabetes, chronic obstructive pulmonary disease, hypertension, obesity and heart disease affect cancer treatment options and outcomes. Black patients have higher rates of comorbidities, some of which can be attributed to SDOH. Obesity, for example, is more common among Black women and is a risk factor for endometrial cancer. Obesity is linked to SDOH such as food affordability and access to healthy food options or safe spaces for physical activity in patients’ neighborhoods, notes Reeder-Hayes.
Some of the largest racial disparities occur in breast, prostate and colorectal cancers. “It’s notable that all of these cancers are screen-
detected, and that social determinants at the health system level and individual level — such as access to insurance, proximity to a screening facility, availability of time off work or transportation — can all affect how likely someone is to get screened and therefore how early their cancer is caught and their chance of being cured,” says Reeder-Hayes. But incidence and mortality patterns differ among cancers. For instance, the risk of prostate cancer for Black men is much higher than for White men, whereas breast cancer incidence among Black women and White women is roughly the same. However, the mortality rate for both cancers is higher for Black patients, which appears related to differences in access to treatment, Reeder-Hayes says.
Oncology Care Model could help
Insurance coverage is another variable in access to cancer treatment. A 2017 study found that only 41% of plans sold on the ACA exchanges had networks that included one of the 71 cancer centers designated by the National Cancer Institute.
“A patient’s choice to go to a top-tier cancer center was essentially cut off because they had insurance through the Affordable Care Act, which, in turn, disproportionately insures minority and lower-income patients and the working poor,” says Reeder-Hayes. “This is an example of social determinants working through the structure of the health system to shunt certain patient groups toward or away from certain types of care — often away from higher quality care.”
Keely Macmillan, M.S., senior vice president for policy and solutions management at Archway Health in Boston and a member of the Managed Healthcare Executive® editorial advisory board, says oncology payment systems haven’t done enough to incentivize care that would address health inequities. “This is partly a reflection of outdated fraud and abuse laws that are prohibitive to innovative ways to address SDOH,” she says. For example, healthcare providers might run afoul of the federal Anti-Kickback Statute if they were to offer transportation or housing assistance, because the statute prohibits offering anything of value in order to get business.
Some good news is that new payment and delivery models are being designed to improve the effectiveness and efficiency of specialty care, including cancer care. CMS’ Center for Medicare and Medicaid Innovation (CMMI) developed the Oncology Care Model (OCM), which aims to incentivize higher quality and more highly coordinated oncology care at the same or lower cost. Under this model, physician practices have entered into episodic payment arrangements that include financial and performance accountability for the total cost of care for patients undergoing chemotherapy.
CMS is also partnering with commercial payers under the model. Practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries, such as care coordination, navigation and national treatment guidelines for care. As of the beginning of last year, 138 practices and 10 commercial payers were participating in OCM.
Some features of OCM could potentially address health equity issues, says Macmillan. Program requirements include a documented care plan for each patient containing the 13 components of the Institute of Medicine’s Care Management Plan, including estimated out-of-pocket costs and a plan to address psychosocial needs. Providers who participate in the model receive real-time monthly enhanced oncology services payments — above and beyond fee-for-service payments — to effectively aid in managing and coordinating patient care. Practices can use this additional funding to hire social workers, patient navigators, community health workers and other staff to support patient care plans.
Other features of the OCM’s pricing methodology that might start to address health inequities include an upward price adjustment for patients who are eligible for Medicaid or who qualify for a low-income subsidy. The adjustment reflects higher costs that come with social risk factors, Macmillan says. In addition, an OCM risk adjustment is scheduled to go into effect February 2021 based on whether the patient has metastatic cancer at diagnosis, according to Macmillan. Because Black patients are more likely to receive a diagnosis of metastatic cancer, the risk adjustment might translate into higher-quality care for Black patients with cancer.
OCM also ties part of the payment to providers to the number of comorbidities a patient has, which acknowledges that care for patients with cancer who have comorbidities may be more complex and expensive, Macmillan says. Because many comorbidities can be traced to SDOH, the additional payment is an indirect way of addressing SDOH in the context of oncology payment.
Incentives for healthcare providers
Incorporating a greater focus on SDOH through value-based payment models that are designed to reward quality of care over quantity could help close the widening disparity gap, says Melanie Teske, senior director of provider payment and network innovation at Blue Cross and Blue Shield of Minnesota. The Minnesota insurer is putting a strong focus on shifting to value-based payment models that enable reimbursement based on health outcomes instead of just the number of billable services provided. As a result, providers are rewarded for addressing SDOH issues outside of services paid for under traditional fee-for-service payment, Teske says.
“Value-based payments incentivize healthcare providers to develop and implement care delivery plans that address health inequities and close gaps in care related to SDOH,” says Teske, who says the Minnesota Blues plan is in the early stages of implementing SDOH programs through these agreements. Teske said the insurer created a pilot program with one local care system in 2020 aimed at measuring the impact of SDOH screenings and refining the payment model accordingly. The Minnesota insurer is planning to expand this and other SDOH-
focused payment models broadly in the near future.
The alternative payment models that CMMI has created include waivers to fraud and abuse laws under certain conditions. “However, it is challenging for providers to implement initiatives to address SDOH when the waiver only applies to a subset of their patient population and when they’re unable to reliably identify attributed patients protected under the waiver,” Macmillan says. “With recent reforms to Stark law [the Physician Self-Referral Law], the Anti-Kickback Statute, and Beneficiary Inducement Civil Monetary Penalty Law, hopefully, there will be novel approaches implemented to achieve health equity.”
Other payment models
Other payment models go further in addressing SDOH. CMMI’s new Direct Contracting Model allows direct contracting entities to offer beneficiary engagement incentives, subject to certain limitations, including vouchers for transportation services, vouchers for nutrition and meal programs, telehealth, and other items and services to support chronic disease management, Macmillan says. CMMI has another payment model, Geographic Direct Contracting Model, that allows providers to offer additional enhancements, including subsidies for Part B premiums, Macmillan says.In the Oncology Care First model, a successor to the Oncology Care Model, CMMI announced its intent to continue paying prospective payments for enhanced services. “These capitated payments could be used to address SDOH,” Macmillan says. More information on the new model is expected in spring 2021.
The Program of All-Inclusive Care for the Elderly, a joint Medicare-Medicaid program designed to keep senior citizens living in their homes, is another payment model that can result in resources going toward mitigating harmful effects of SDOH. Participants and their caregivers meet with an interdisciplinary team that includes physicians, nurses, therapists, social workers, dietitians, personal care aides, transportation drivers and others, Macmillan says. Their needs are assessed, and an individualized care plan is developed.
More needs to be done
Although some see the aperture of oncology payment slowly beginning to widen to consider SDOH, the focus remains on medical services. In future models, Macmillan says CMS must adopt better ways to account for the effect of SDOH on cost: “The current methodology relies on comorbidities that have been previously documented, and SDOH can inhibit access to care and reduce the likelihood that comorbidities have been previously documented.”
According to Reeder-Hayes, “The strongest predictor of a patient’s chances of beating cancer should not be his or her location, race, income or occupation. Every person deserves a fair opportunity to get high-quality cancer care that’s matched to their needs and values. With some of the most advanced healthcare technology in the world, that is possible.”
“We need to figure out how to design the health system to deliver that fair opportunity,” Reeder-Hayes continues. “If we care enough to invest in data collection about the social circumstances of patients, measure differences in the care delivered based on social factors, make adjustments based on findings, try again and remeasure, we can continue to learn how to be better.”
Along these lines, Manali I. Patel, M.D., M.P.H., M.S., assistant professor of medicine at Palo Alto Veteran Affairs Health Care System, says it will take a village to overcome barriers influenced by SDOH on cancer payments. “It’s important to consider how to ensure that SDOH are identified for patients,” she says. “In some cancer settings, navigators or community health workers have served in that role. Addressing SDOH requires a team-based approach between patients and their caregivers, oncology providers, community-based organizations, payers and policy makers to ensure that multi-level interventions are enacted.”
Karen Appold is a medical writer who lives in the Lehigh Valley region of Pennsylvania.