For clinical pathways to be most effective, they need to accommodate many external factors impacting patients. These include issues such as the social determinants of health, as well as access to care that can impact health outcomes—especially for vulnerable Medicare patients. Taking into account these critical factors is essential for the development and execution of truly patient-centered clinical pathways.
Social Determinants of Health
The social determinants of health take into account when and where people are born, live, work, and how these attributes affect their health. The federal initiative Healthy People 2020 emphasizes the importance of social determinants of health, stating that social and physical determinants of health impact a wide range of health, functioning, and quality-of-life outcomes. Social and physical determinants of health are often the result of decisions made at the higher levels of society.1
The basis for inclusion of social determinants of health starts in our homes, schools, workplaces, neighborhoods, and communities. Health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships.
Healthy People 2020 emphasizes the importance of addressing the social determinants of health by including “…social and physical environments that promote good health for all” as one of the four overarching goals for the decade. This emphasis is shared by the World Health Organization (as described in Table 1), and other United States–based health initiatives such as the National Partnership for Action to End Health Disparities and the National Prevention and Health Promotion Strategy.
The social determinants of health topic area within Healthy People 2020 is designed to identify ways to create social and physical environments that promote good health for all. These factors need to be taken into account when developing clinical pathways to achieve optimum health outcomes.
Access to Care
To assess the impact of access to care, we must take into account not only the current level of care but clinical history as well. This relates to the potential issue of patients coming into Medicare after a lengthy period of being uninsured. It also relates to access issues beyond insurance coverage. Patients may find it difficult to set an appointment when a provider has limited availability, or may encounter transportation issues getting to and from an appointment. Without issues of access to care, a clinical pathway would call for patients to be screened at a certain age and then referred to a specialist. But if the timing of this screening is based on limited care because of lack of insurance coverage or inability to get an appointment, the clinical pathway is of no value.
Because of changes in insurance coverage, there are three major factors likely to impact Medicare beneficiaries. As a result of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its Quality Payment Program (QPP), the shift to value-based care is responsible for outcomes for both payers and providers, as outlined in Table 2. These factors need to be taken into account when developing clinical pathways to guide Medicare patients and providers through the Initial Preventive Physical Examination (IPPE), also known as the “Welcome to Medicare Preventive Visit.”3 The IPPE is available to the 10,000 new Medicare beneficiaries entering Medicare daily, which equals approximately 3,650,000 visits per year.
The goals of the IPPE are health promotion, disease prevention, and detection. Medicare pays for one IPPE per beneficiary per lifetime for beneficiaries within the first 12 months of the effective date of the beneficiary’s first Medicare Part B coverage period. Each of these Medicare beneficiaries is likely to be impacted by three unique issues facing Medicare as a result of health care reform.
Current Medicare Patients
Current Medicare beneficiaries are going to be cared for by providers operating on the new MACRA value-based programs. Given the complicity of the QPP, many providers may drop out of the Medicare program, resulting in decreased access. As a result, many clinical pathways will need to be adjusted to take access restrictions into account. Primary care providers will be called upon to perform more duties, such that the limited access to specialists can be best utilized.
Dual Eligibles
The expected shift of federal funding based on the number of Medicaid recipients in each state to block grants will reduce the federal contribution to Medicaid, resulting in decreasing the number and coverage of Medicaid patients. As a result, many Medicare beneficiaries who are currently covered by Medicare and Medicaid will lose this dual coverage, meaning they will be subject to 20% out-of-pocket costs for most services. This will cause the need for pathway redesign, since many beneficiaries will be unable to afford some services.
Pre-Medicare
With the certain reduction in coverage and raising costs of individual insurance through the Health Insurance Marketplace, many pre-Medicare individuals will be underinsured or uninsured. As a result, patients may forgo needed chronic care management and preventive care, and will enter Medicare in need of immediate care. This will impact pathways, as providers will need to be prepared to treat Medicare beneficiaries with deferred care issues.
Conclusion
For clinical pathways to be most effective, they need to adjust to the many external factors impacting patients, such as social determinants of health and access to care. Those clinical pathways that succeed in delivering the triple-aim of cost, individual patient experiences, and population health need to take into account these critical and increasingly complicated external factors.
References
1. Healthy People 2020. Healthy People website. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed July 23, 2017.
2. The determinants of health. World Health Organization website. https://www.who.int/hia/evidence/doh/en/. Accessed July 23, 2017.
3. Get your patients off to a healthy start in 2015 with the AWV and the IPPE. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Health-Observance-Mesages-New-Items/2015-01-08-AWV-IPPE.html. Accessed July 23, 2017.
