Adding Social Determinants to CMS’ Universal Foundation a Key Step Forward

February 27, 2023 - CMS wants you to be able to use a standard set of quality measures for the myriad value-based care contracts you might be involved in. Dubbed the Universal Foundation, these measures are set to streamline quality reporting in different contracts. The most exciting part? They include social determinants of health screening and the ability to quantify health disparities.

The agency outlined the Universal Foundation in a February 1 article in the New England Journal of Medicine, explaining that in their 20-year history, quality measures have become more complex, redundant, and in some cases meaningless to improving clinical quality. Although integral to moving value-based care forward, quality measures can be a headache for many in the healthcare industry.

“Since there is tension between measuring all important aspects of quality and reducing measure proliferation, we are proposing a move toward a building-block approach: a ‘universal foundation’ of quality measures that will apply to as many CMS quality-rating and value-based care programs as possible, with additional measures added on, depending on the population or setting,” CMS leadership wrote in the NEJM article.

The proposed Universal Measures include 23 measures ranging from preventive care and screenings, behavioral health, and chronic disease management. These measures, which CMS has made room to iterate in the future, would start as a baseline and some programs might require supplemental measures. The agency emphasized that additional measures would go under strict scrutiny before being added to program requirements.

To much celebration from Gary Price, MD, the CEO of the Physician’s Foundation, the measures also include two that look at the social drivers of health.

“The first one is just the percent of beneficiaries 18 years and older who were simply screened for five drivers of health measures,” Price told PatientEngagementHIT in a recent phone call.

Those particular social drivers include food security, housing instability, transportation access problems, access to utilities, and interpersonal safety.

“That's just asking how many of the people you saw of that demographic were actually asked about these things. Pretty simple place to start,” Price stated.

In a second, follow-up measure, the Universal Foundation looks at the percentage of those screened over age 18 who were actually positive for one of those social drivers. It’s a modest place to start, but you have to start somewhere, Price said, and that’s something to be proud of.

“Those two measures are the first two ever to address drivers of health as far as our federal healthcare system is concerned in the Medicare or Medicaid system, which of course is really significant,” he said. “It's the first time there's been any attempt to look at those influences on healthcare. We now know that perhaps as much as 70 percent of healthcare outcomes and costs are related to those factors rather than the clinical and technical things we do in healthcare.”

Getting it right on quality measures

In some ways, the Universal Foundation is a CMS effort to course correct on quality measures. Quality measures are instrumental to any quality improvement program, including certain value-based care programs. As the old adage goes, you cannot improve what you do not measure.

But as both CMS and Price indicated, those quality measures had become overly complex. Different programs might measure different outcomes, or they might be looking at the same outcome but use different language when detailing the measure.

“One of the problems with the quality measures up to this point is that they often weren't aligned with each other either within the coding system itself or between hospitals and physicians or even between different insurers and the way they're coded,” Price explained. “That's become kind of a mess, and I think CMS has signaled that they want to help improve that.”

Simplifying quality measures across programs should intrinsically have an impact on provider workloads. But importantly, the Universal Foundation seeks to measure only what’s important, which will help physicians focus on what’s most meaningful to their jobs. And according to Price and the Physicians Foundation, that’s getting to the root drivers of patient health.

In a 2022 Physicians Foundation survey, nearly 90 percent of doctors said they’d like to look deeper at social determinants of health, but they don’t have the time or the tools to do so. Simplifying quality measurement and adding measures about social drivers of health is a remedy to that, Price stated.

“The very fact that these two first-ever measures now are part of those fundamental 23 building blocks signals a real intention and a real focus on these factors as part of the way we think about healthcare,” he explained.

Developing the drivers of health measures

Price and his team at the Physicians Foundation are excited about the addition of social drivers to such a universal set of quality measures. After all, the Physicians Foundation has been arguing the importance of social determinants of health since its inception in 2003.

After years of funding research, all of which concluded that health outcomes vary by zip code and socioeconomic status, the organization looked at how physicians could fix this. Leaving social drivers out of the quality measurement conversation was a burnout problem for providers, that 2022 survey showed.

It also created a gulf in reimbursement for those clinicians serving a disproportionately underserved population.

“We also funded research that revealed that physicians who had a heavy burden of patients with these sorts of drivers of health needs that those physicians not only weren't incentivized under our current reimbursement system, but they were actually penalized,” Price added. “They could deliver the same care, but they would get paid less because of the impact of these drivers of health on their patients' healthcare outcomes and their costs.”

That prompted the Physicians Foundation to develop a list of 17 different healthcare policy changes that could help address the problem of unaddressed social drivers, physician burnout, and reimbursement woes. Those recommendations ranged from reducing measures that Price said can sometimes be meaningless and increasing funds to address SDOH barriers to certain preventive services, like getting vaccinations.

In response, CMS actually approached the Physicians Foundation to ask them to create measures on the drivers of health.

“There's a very complicated process to go through to get measures like that into our federal healthcare system, but we navigated all that with the help of an organization called The Health Initiative,” Price said, adding that the measures were formally adopted in August 2022.

The two measures—how many people get screened and how many screen positive for SDOH—are simply a launch point, Price affirmed. Other organizations have begun to submit measures that build upon the two the Physicians Foundation submitted, and Price stated that in the future more measures related to social drivers of health will be essential for moving the needle on outcomes for all.

Part of that evolution must stem from the physician perspective, Price cautioned. Just look at the widespread incentive programs for EHR adoption; that process at the organization and policy level didn’t cater to the buy-in of the whole healthcare team, and it was long and arduous and resulted in the retirement, career change, or burnout of many clinicians, Price recalled.

“I think electronic health records were to a very large degree imposed on all of us from a top-down approach, and it was a huge mistake, and I'm just hoping when we do that with this, that we can get better at that,” he said.

Universal Foundation accounts for health equity measure

Central to the Universal Foundation that CMS developed is the ability for it to look at health equity. CMS explained that each of the 23 measures in its preliminary foundational set, which includes the two Price and his organization created, can be stratified by race to identify points of health disparities.

Looking at preventive care access by race, for example, could reveal where outcomes differ by population and help inform work to remedy that.

“It's tremendously important because we know a fair number of the inequities in our healthcare system as far as outcomes go, and even cost, are associated with race,” Price noted. “We know that Black Americans have tremendous inequities in their outcomes with certain diseases.”

In terms of social drivers of health, Price said that looking at these measures by race will reveal information about patient care and social circumstances that could influence outcomes.

Healthcare experts haven’t usually had that information, he added. They’ve been able to see differences in disease management or even healthcare costs. But when experts can also see differences in social drivers, it will give a new window into how to improve outcomes across all racial groups.

“We can't hope to improve the quality of what we do, and we can't hope to improve the equity of the way our healthcare is delivered, without addressing those things,” Price concluded. “So, we're tremendously proud that the Physicians Foundation, which represents all the doctors in the US, was behind getting what was really a momentous policy decision through the Byzantine nooks and crannies of our bureaucracy.”