Is Your ACO Maximizing its Performance by Identifying Social Determinants of Health and HCC Conditions?

Is your ACO maximizing its performance by identifying Social Determinants of Health and HCC conditions?

Correct identification of the social determinants of health (SDOH) factors and the hierarchical condition category (HCC) codes for patients is crucial for accountable care organizations to appropriately address attributed patients’ needs. Data from both SDOH and HCC are important in identifying high-risk patients who may benefit from additional services, management, or other interventions. Social Determinants of Health data and hierarchical condition codes identify these patients but do so in different ways.

Social Determinants of Health refer to conditions and environments in which people
are born, live, learn, and work. These factors influence an individual’s health outcomes and fall into several categories:
1. Economic Stability: Economic Stability information includes income level, employment status,
and financial security. People with steady employment are less likely to live in poverty and tend to have better health outcomes. Lower-income individuals face higher healthcare costs relative to their income. They may experience barriers to accessing preventative care, which tends to lead ultimately to more expensive emergency interventions and negative health consequences later. People with stable and sufficient income are better able to access healthy food, safe housing, and timely healthcare.

2. Education: Access to quality education and educational attainment leads to improved health literacy. Children from low-income families, children with disabilities, and children who routinely experience forms of social discrimination are more likely to struggle with math and reading. They are also less likely to graduate
from high school or go to college, resulting in the potential for reduced health literacy. People with lower health literacy might not understand how to manage their chronic conditions effectively, leading to more frequent and more costly healthcare interventions.

3. Social and Community Context: Social and Community Context information can help Accountable Care
Organizations understand an individual patient’s support networks, community safety and resources or lack thereof. Lack of social support can lead to poor health outcomes and higher costs as individuals struggle to
follow treatment plans and manage their own health conditions. Lack of social support networks or community engagement as well as experiences of discrimination or violence all have negative impacts on health.

4. Healthcare Access and Quality:
Assessment of the availability of healthcare services, insurance coverage, and the quality of care available to patients provides insight into potential health outcomes. Those without adequate insurance or living in areas with limited healthcare facilities may face higher costs due to delays in care or the need to travel long distances for treatment. Healthcare access and quality have direct effects on individuals receiving timely and appropriate care.

5. Neighborhood and Built Environment: Addresses housing quality, access to healthy foods, and other environmental conditions. Poor living conditions or lack of access to a healthy diet can lead to the worsening of chronic health conditions that ultimately increase the cost of healthcare and decrease health outcomes. Social Determinants of Health are conditions that are non-medical but impact the health, health outcomes, and overall well-being and longevity of individuals. Social Determinants of Health may be identified using several different coding systems such as ICD-10 Z codes and Snomed CT codes.

ICD-10 Z codes

 Z codes identify factors influencing an individual’s health status that are not classified elsewhere as diseases, injuries, or other external causes. Certain ICD-10 Z codes, Z 55–Z 65, address social factors that may impact health. SDOH data is important in understanding issues such as housing insecurity, food insecurity, or lack of transportation. These codes are also used to capture data related to education, employment, social environment, and other
socioeconomic factors.

Snomed CT codes
Snomed codes are also used to code SDOH information. Understanding and addressing Social Determinants of Health can help mitigate care costs and improve health outcomes by targeting the root causes of healthcare
disparities and barriers to access to care. Hierarchical Condition Categories (HCC) codes are used to categorize patients based on their chronic health conditions and to identify potential patient risks and costs associated with these chronic conditions. They are also useful to identify patients for whom care opportunities or care gaps may exist. HCC codes are also part of the risk adjustment models in which specific ICD-10 codes identify patients with higher severity of illness or conditions and anticipated higher healthcare costs. Each HCC code adds to the patient Risk Adjustment Factor (RAF) and contributes to the overall risk score for a patient, which in turn impacts payment rates for Medicare Advantage patients ACOs should invest the resources to assess and understand the SDOH factors and chronic conditions that impact the populations that the ACO serves. The goals of improving the health of individuals and lowering the total cost of care that ACOs strive for will not be possible without insight into all the factors that ultimately impact an individual’s health outcomes. If your ACO is not able to access or utilize the data sources it has to identify SDOH and HCC information consider partnering with a trusted partner, like ReportingMD, to manage this valuable data source