SDoH at the Intersection of Healthcare Quality

EDITOR’S NOTE: This story is the result of JAMA Viewpoint article by Dr. Jorge Portuondo from the Center for Innovations in Quality, Effectiveness, and Safety out of the Veteran’s Administration Medical Center in Houston.  Portuondo and colleagues released their opinion piece July 29, titled, “Using Administrative Codes to Measure Health Care Quality.” 

The Portuondo article questions the value or impact of using diagnosis and procedural codes to measure health care quality. This makes me think of our previous debate about the underutilization of SDoH Z codes and the requirements to fall within the list of diagnosis and procedural codes.

Z codes have no quality or financial ties for reimbursement. In Portuondo’s discussion, he considers how directly tying diagnosis and procedural codes to value-based performance could create an opportunity to “game the system” so hospitals can optimize their coding practices to maximize reimbursement or performance on quality-based initiatives. I got a little defensive in my head reading this article. Thinking this is “not all hospitals” as we know that Medicare Advantage plans have also played their part with incentives to increase their patient RAF scores. In September 2021, the Office of the Inspector General (OIG) released their findings on a subset of Medicare Advantage plans having “suspicious” behavior related to their health risk assessments and diagnosis coding which significantly increased their risk-adjusted payments from the Centers for Medicare & Medicaid Services (CMS). Let’s consider the question  ”If we continue to tie quality to reimbursement are we artificially depicting the value of care we are delivering?”     

Obviously, this kind of article and the OIG reports in the last couple of years regarding coding has raised some opinions. We know patients receiving hospital care are likely more complex and likely do have comorbid conditions. However, we also understand that the publicly reported incentives from CMS for quality programs and reimbursement programs have changed coding practices due to the documentation capture requirements. Thankfully, the report and others, such as publications from the Commonwealth Fund have asked CMS to consider a separation of quality data registries from the coding and procedural billing codes. Hospitals are already required to report a significant amount of quality data to CMS across a spectrum of clinical specialties and disease registries. Could these mechanisms be used in a more meaningful way than the administrative data used for billing purposes?   

So, let’s go back to the consideration of SDoH, I propose a hypothetical question to our audience should we continue the route of reporting Z codes as a coding process in line with our current coding procedures or should there be a separate means for capturing SDoH data? 

  • Keep it the same (current Z codes)
  • Create a new mechanism for SDoH data
  • Unsure

The responses from the Monitor Mondays listener survey may surprise you, and can be viewed here.

Programming Note: Listen to Tiffany Ferguson live reporting on the SDoH every Monday on Monitor Mondays at 10 Eastern.

References:

Using Administrative Codes to Measure Health Care Quality | Health Care Economics, Insurance, Payment | JAMA | JAMA Network

https://oig.hhs.gov/oei/reports/OEI-03-17-00474.pdf

https://www.commonwealthfund.org/blog/2022/taking-stock-medicare-advantage-risk-adjustment

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Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

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