Almost 100 years since Calvin Coolidge spoke of the government as a “device for maintaining in perpetuity the rights of the people, with the ultimate extinction of all privileged classes,” socioeconomic factors remain one of the most clinically significant contributors to health outcomes in this country. This statement serves as the opening for ACP's recent policy paper, “Reforming Physician Payments to Achieve Greater Equity and Value in Health Care,” but it also serves as a theme throughout the College's policy and advocacy efforts. We must be intentional in our efforts to address the needs of individuals who are experiencing health care disparities and inequities based on personal characteristics and/or are disproportionately impacted by social drivers of health (SDOH).
Over the past few months, ACP has released several new policy papers focused on health equity and SDOH. “Reforming Physician Payments to Achieve Greater Equity and Value in Health Care” builds on the College's 2020 new vision, “Better Is Possible: ACP's Vision for the U.S. Health Care System,” and contains a number of innovative recommendations. Reflecting on the National Academies of Science, Engineering, and Medicine's report “Implementing High-Quality Primary Care,” ACP's paper pushes for hybrid (part fee-for-service, part capitated) payment models, as well as for population-based, prospective payment models to prioritize the needs of underserved patient populations and those who are disadvantaged by health care disparities and inequities.
However, these changes will not occur without intentional policies and approaches. Fixing these problems requires thinking outside the box when adjusting for risk, given that hierarchical condition category coding fails to adequately account for SDOH, the overlap of multiple conditions, and severity of conditions, among other important factors. There are innovative methods of risk adjustment available for consideration (e.g., neighborhood stress score, area deprivation index). Payers, including Medicare, need to consider incentives for physicians and practices that are willing to engage in experimentation in this area, protecting them from downside risks via safe harbors or other means.
ACP was able to share these recommendations and several others in response to a recent request for information as part of the HHS Initiative to Strengthen Primary Health Care. We are also encouraged by the recent CMS proposal to add a health equity adjustment to performance measures within the Medicare Shared Savings Program; however, we will need to monitor this closely to ensure that it does not lead to unintended consequences for either patients or physicians. CMS is seeking comments on potentially using a health equity index in the Medicare Advantage Star Ratings Program. There are also proposals to better address health equity and disparities within the Part D program, the Hospital Readmissions Reduction Program, dual-eligible special needs plans, and the Hospital Inpatient Quality Reporting Program.
A second recent ACP paper, “Strengthening Food and Nutrition Security to Promote Public Health in the United States,” focuses on food insecurity as a specific SDOH, noting that it directly affects health, which can further harm employment and income and increase medical expenditures—all of which circle back to further exacerbate food insecurity. The College urges policymakers to prioritize addressing food insecurity and nutritional drivers of health, specifically calling for improvements to the Supplemental Nutrition Assistance Program. In line with the paper on payment reform, we urge CMS to develop, test, and support innovative models and waivers that incorporate benefits and activities that address SDOH, including food insecurity.
ACP has also called for intentional policies and approaches to ensure that older adults and those with cognitive or physical disabilities have the best quality of care possible, particularly given the significant impact of the COVID-19 pandemic on nursing homes and other long-term service and support facilities. This paper, titled “Long-Term Services and Supports for Older Adults,” notes that the number of Americans ages 65 years or older is expected to grow from 56 million in 2020 to 73 million in 2030, comprising roughly 20% of the population. Additionally, older Americans will be more racially and ethnically diverse in the coming decades. This paper includes several recommendations related to financing and workforce needs for long-term services and support—and, aligned with the papers mentioned earlier, it calls for continued development and implementation of evidence-based nursing home quality measures and models to improve care coordination, care transitions, health equity, resident and family experience, and discharge planning.
Finally, it is important to note that ACP's policy and advocacy related to women's health care encompasses and goes beyond access to direct reproductive health care services like abortion. Another issue on which we're engaged is access to menstrual products. Social and economic barriers inhibit adequate access to menstrual hygiene products and education in the U.S., particularly for vulnerable populations including school-aged children, those experiencing homelessness, low-income individuals, and incarcerated individuals. This can also be called “period poverty.” One study published in the February 2019 Obstetrics & Gynecology found that 64% of low-income women were unable to afford needed menstrual hygiene products in the past year, while 21% experienced this monthly; 46% couldn't afford both food and menstrual hygiene products in the past year. To address this issue, ACP has developed an action toolkit that will allow chapters in states that tax menstrual hygiene products to engage their state policymakers on the need to exempt these products from state and local taxes.
The World Health Organization defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” There is simply no way to truly achieve health for the U.S. population without intentionally addressing the needs of those experiencing disparities or inequities. We must have greater investment in public policy interventions that address SDOH and other factors that negatively impact health. ACP calls on our members, policymakers, and other key stakeholders to join with us in intentionally improving the health and well-being of everyone, particularly the most vulnerable in our society.