Medical cohort episodes and social determinants: A match made for health equity and program integrity

July 26, 2021 / By Private: Katie Christensen

The COVID-19 pandemic has heightened our awareness of the disparities in health equity: accessibility to health care facilities; individual ability and awareness to attend to health care management; support systems to address individual and/or community disadvantages; the list is endless. 

The natural response to any significant public health event is to look back and ask yourself:

• What could I have done better?
• What would I have done differently had I known then what I know now?
• How could I have managed the care process more effectively so that we not only achieved better outcomes, but also better overall health care management?

So, how can we learn from our experiences?

While each claim in a utilization-based reimbursement model can provide insight, we must look across time, respecting the individual circumstances of each patient. With an understanding of social and clinical risk, we can identify patterns of care which resulted in poorer health outcomes, lower compliance with general standards of care, lower quality and potentially a higher rate of emergency room visits. 

The impact of socio-clinical risk

The data shows us that a disproportionate contribution to both total cost of care and preventables comes from individuals with chronic conditions. The relatively small number of members with multiple complex conditions disproportionately explain total cost of care as well as 3M™ Potentially Preventable Events (PPEs), such as 3M™ Potentially Preventable Emergency Department Visits (PPVs), 3M™ Potentially Preventable Admissions (PPAs) and 3M™ Potentially Preventable Readmissions (PPRs).

Add to that the social risk which provides further explanation of disease progression and ED utilization, PPEs and varying patterns of utilization and spend. As evidenced through a recent pilot study, virtually every area of social risk (health literacy, transportation barriers, food insecurity, housing instability and financial strain) resulted in higher than expected ED utilization. The members with high social risk were sicker, and even after adjusting for that, still went to the ED more. 

We also saw that less serious ailments like sleep apnea weren’t necessarily on the list of chronic conditions. Although it doesn’t have the same visibility as, say, congestive heart failure, it can warrant elevated care coordination attention, particularly when accompanied by high social risk.

Members with high social risk, specifically related to healthy literacy, showed a higher rate of developing an additional co-morbid condition. Members with high social risk also showed some evidence of getting sicker at a faster rate.

All of these factors point to the application of a person-centric, socio-clinical approach that does not define an individual in terms of a singular condition. A patient is more than a diabetic. And a person is more than an individual with food insecurity and high social risk. These examples build on our industry recognition of the role of chronic conditions while additionally leveraging our insight into the effect of social risk as we manage our populations who are most in need. 

Using episodes for program integrity

An episode is a window in the clinical experience, for example a hip or knee replacement. We have a “leading” window, followed by the actual procedure, and then what is called the “trailing” window which represents an opportunity to implement care practices to prevent acute onset. These are “event” episodes.

A medical cohort episode focuses on chronic conditions. It represents a period of time and are not so focused on managing a procedure like hip replacement, but managing the patient through a person-centered approach. It captures individuals with diabetes who may also have a myriad of other socio-clinical risk that we need to address holistically. What can I do with this person, this population, to minimize the need for surgery or to minimize acute onset for members with diabetes? 

It’s good to manage the surgery event more effectively, but how can I work to eliminate the need for surgery in the first place?

Therein lies the opportunity to be proactive with this population of individuals with heightened socio-clinical risk. Make sure they are going to their primary care provider (PCP) and picking up their medications. If they see other specialists, be proactive when there is multiple specialist activity, a change in medications, or when an appointment is missed or a trip to the ED occurs.

We have standards of care that we know are critical for managing populations, both minimizing the risk of disease progression as well as acute onset that requires a trip to the hospital, a stay in the emergency room and/or an inpatient admission. Apply these rules as part of a program and prioritize your populations to those with heightened socio-clinical risk.

Episodes are often described as messy. They are different and don’t mesh easily with our utilization, claims-based model.

Let’s not let ease of application get in the way of innovation. Episodes were not necessarily borne with a program integrity use case, but it certainly seems like the logical application given our learnings from COVID-19 on health care disparities.

Katie Christensen is a healthcare consulting manager within the Population and Payment Solutions group of 3M Health Information Systems.

Identify patient-focused episodes using a clinical model that categorizes episodes of care to reflect a patient’s total burden of illness.