Let’s begin by defining the two key elements of this topic. Social Determinants of Health (SDOH), as established by the World Health Organization, are the conditions in which people are born, grow, live, work, and age. These conditions can greatly influence a person’s health, quality of life, and even their lifespan. They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care.
On the other hand, the Star Rating Quality Measures by the Centers for Medicare and Medicaid Services (CMS) is a system designed to measure the quality of health care services provided by hospitals and health plans. These ratings take into account factors such as health outcomes, access to care, and beneficiary satisfaction.
The intersection of these two elements is crucial, as the CMS Star Ratings not only impact the quality and type of care that patients receive, but also the reimbursement rates for care providers.
What becomes clear is that the Social Determinants of Health can dramatically influence these star ratings. For instance, let’s consider access to transportation, a typical SDOH. In areas with poor public transportation or in rural regions where medical facilities are few and far between, patients may find it challenging to attend regular check-ups or receive necessary treatments. This lack of access to care can directly impact several of the Star Rating measures, such as preventative care and chronic disease management, resulting in lower star ratings.
Similarly, consider another SDOH, educational level. Research has shown a correlation between lower education and poor health outcomes. Less education can translate into less understanding of medical information and instructions, leading to poorer adherence to prescribed treatments and worse outcomes. This, in turn, can negatively affect the star rating based on health outcomes and patient satisfaction.
However, it’s important to note that the CMS is increasingly recognizing the impact of SDOH on health outcomes and patient satisfaction. In recent years, CMS has made efforts to incorporate SDOH into their models, considering factors like income, education, and environment. This is a promising step toward addressing these critical influences on health.
One such potential effort is the significant change announced in the Fiscal Year 2024 Inpatient Prospective Payment System (IPPS) draft rule. In this draft rule, the CMS has made an important advancement by including Social Determinants of Health codes for homelessness, which will be classified as Complications or Comorbidities (CCs) if the draft rule makes it to final (usually sometime in August).
The specific codes are the following:
The inclusion of these codes means that healthcare providers will now be financially incentivized to screen for and document homelessness. This is a huge stride towards understanding and addressing the impact of homelessness on health outcomes.
Homelessness is a profound social determinant of health. It is associated with a range of health issues, including chronic diseases, mental health disorders, and higher mortality rates. Homeless individuals often face barriers to accessing quality health care, which further exacerbates their health conditions.
However, with the new IPPS draft rule, providers can now get reimbursed for the extra care that these individuals require. For example, a homeless person might need more time, resources, or specialized interventions to manage a chronic condition compared to a housed individual. Now, the CMS recognizes these challenges and is compensating providers accordingly.
Moreover, this change also helps elevate the visibility of homelessness as a health issue. Providers are now encouraged to document homelessness, contributing to a richer dataset for researchers and policymakers. This data will be critical in understanding the true impact of homelessness on health and how the health system can better serve this vulnerable population.
This shift in the CMS approach is a significant indication of the growing recognition of the role of SDoH in shaping health outcomes. By financially recognizing the additional complexity associated with caring for homeless individuals, CMS is setting a precedent for how we can make our healthcare system more sensitive to SDOH, driving us towards a future where we can provide comprehensive, accessible, and equitable care for all.
Still, more can be done.
Health systems and payers must find ways to mitigate the impact of social determinants on health outcomes. This could include innovative solutions such as partnerships with community organizations, investment in social services, and adoption of technology to reach patients who might be physically distant from care.
In conclusion, the intersection of SDoH and the CMS Star Ratings is a vital issue. Ignoring the profound influence of SDOH can result in lower star ratings, potentially affecting the quality of care that patients receive.
Recognizing and addressing these determinants, therefore, is crucial not just for maintaining high-quality healthcare services, but for ensuring equitable care for all, regardless of their circumstances. The health care system must evolve to be more sensitive to these factors, integrating them into their strategies for improvement and innovation. The new changes in the IPPS draft rule further underline this fact. As we move forward, we need to continue this momentum, incorporating more SDOH into our healthcare practices and policies. Because in the end, a high-quality healthcare system is one that caters to everyone, irrespective of their social or economic conditions.
The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs)
External audit volume more than doubled in 2024 over 2023 while total at-risk dollars increased fivefold to $11.2 million, impacting healthcare provider organizations’ cash flow
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