Systems Practices
FOR THE CARE OF
Socially At-Risk
Populations
Committee on Accounting for Socioeconomic Status in Medicare Payment Programs
Board on Population Health and Public Health Practice
Board on Health Care Services
Health and Medicine Division
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by Contract No. HHSP233201400020B from the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-39197-9
International Standard Book Number-10: 0-309-39197-0
Document Object Identifier: 10.17226/21914
Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
Copyright 2016 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016. Systems practices for the care of socially at-risk populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Ralph J. Cicerone is president.
The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.
The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.
The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.
Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org.
This page intentionally left blank.
COMMITTEE ON ACCOUNTING FOR SOCIOECONOMIC STATUS IN MEDICARE PAYMENT PROGRAMS
DONALD M. STEINWACHS (Chair), Professor, Johns Hopkins Bloomberg School of Public Health
JOHN Z. AYANIAN, Alice Hamilton Professor, Director, Institute for Healthcare Policy and Innovation, University of Michigan
CHARLES BAUMGART, Senior Medical Director, xG Health Solutions
MELINDA BUNTIN, Professor and Chair, Department of Health Policy, Vanderbilt University School of Medicine
ANA V. DIEZ ROUX, Dean and Distinguished Professor of Epidemiology, Drexel University School of Public Health
MARC N. ELLIOTT, Senior Principal Researcher, RAND Corporation
JOSÉ J. ESCARCE, Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles
ROBERT FERRER, Dr. John M. Smith, Jr. Professor, Department of Family & Community Medicine, University of Texas Health Science Center at San Antonio
DARRELL J. GASKIN, William C. and Nancy F. Richardson Professor of Health Policy and Director, Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health
MARK D. HAYWARD, Professor of Sociology, Centennial Commission Professor in the Liberal Arts, Faculty Research Associate, Population Research Center, The University of Texas at Austin
JAMES S. JACKSON, Daniel Katz Distinguished University Professor of Psychology, Research Professor, Institute for Social Research, University of Michigan
DANIEL POLSKY, Executive Director, Leonard Davis Institute of Health Economics, University of Pennsylvania
MEREDITH ROSENTHAL, Professor of Health Economics and Policy, Harvard T.H. Chan School of Public Health
ANTHONY SHIH, Executive Vice President, The New York Academy of Medicine
Study Staff
KATHLEEN STRATTON, Study Director
LESLIE Y. KWAN, Associate Program Officer
EMILY VOLLBRECHT, Senior Program Assistant
REBECCA MORGAN, Senior Research Librarian
DORIS ROMERO, Financial Associate
HOPE HARE, Administrative Assistant
ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice
SHARYL NASS, Board Director, Board on Health Care Services
This page intentionally left blank.
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
RONALD M. ANDERSEN, University of California, Los Angeles
MICHAEL CHERNEW, Harvard Medical School
MARSHALL CHIN, University of Chicago
JACK EBELER, Independent Consultant
LEE FLEISHER, University of Pennsylvania School of Medicine
PATRICIA A. GABOW, University of Colorado School of Medicine and formerly Denver Health
DAVID R. NERENZ, Henry Ford Health System
THOMAS RICE, University of California, Los Angeles, Fielding School of Public Health
STEPHANIE ROBERT, University of Wisconsin–Madison
JOSHUA M. SHARFSTEIN, Johns Hopkins Bloomberg School of Public Health
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by GEORGES C. BENJAMIN, American Public Health Association, and CHARLES E. PHELPS, University of Rochester. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
This page intentionally left blank.
Acknowledgments
Many individuals generously provided case studies to the committee during the course of the deliberations leading to this report. In particular, the committee thanks Susan Hayes, Martha Hostetter, and Douglas McCarthy of The Commonwealth Fund. In addition, the committee extends thanks to Lynne Cuppernull and Howard Shapiro of the Alliance of Community Health Plans, Mark Hamelberg of America’s Health Insurance Plans, Susan Knudson of HealthPartners Minnesota, John Lovelace of the UPMC Health Plan, Sanne Magnan of the Institute for Clinical Systems Improvement, Dana Safran of Blue Cross Blue Shield of Massachusetts, and Bruce Siegel of America’s Essential Hospitals.
This page intentionally left blank.
Contents
Committee Process and Approach
2 IMPROVING CARE FOR SOCIALLY AT-RISK POPULATIONS
Performance of Providers Disproportionately Serving Socially At-Risk Populations
Practices to Improve Care for Socially At-Risk Populations
Evidence Base for the Six Systems Practices
Resource and Sustainability Considerations
Opportunities to Address the Gaps in Knowledge
Putting This Report in Context
