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Improve Revenue Cycle Management Processes to Enhance Health Equity
While genes and biochemistry clearly influence health, one’s living conditions are a bigger variable. Unfortunately, we as integrated health leaders are missing a huge opportunity to address this larger part of the health equity equation.
Data drives solutions. We need to pay more attention to useful data on the externalities that fuel inequity, or social determinants of heath (SDOH). Capturing and leveraging this data can improve outcomes for patients, providers, and our healthcare system as a whole.
Positive social conditions are associated with improved patient outcomes and lower costs, while worse conditions negatively affect hospital readmission rates, length of stay, and use of post-acute care. More than 2 out of 3 consumers say they have some SDOH risk. Those with high SDOH stress are nearly 50% more likely to suffer from chronic conditions and 2.3 times more likely to rate their health as “fair” or “poor.”
Inequity Can Hurt
Consider the following scenario: A homeless woman contracts a urinary tract infection and receives a prescription for antibiotics. Focused on finding food to eat and otherwise distracted by long-term psychological challenges, she misses half her doses. This enables the infection to linger and worsen. Not surprisingly, she develops grave complications and winds up in the emergency room with a dozen people working on her. It is a situation that is excruciating, avoidable, and expensive.
As one doctor writes, stories along these lines exemplify a medical system “quick, massive, powerful, able to assemble a team in under an hour and willing to spend thousands of dollars when a patient is sick,” but somehow prone, perhaps, to letting her get that way.
Fortunately, there’s increasing attention on how living conditions affect behavioral health. Low socioeconomic status correlates with increased risk of depression or anxiety. Disadvantaged communities face higher rates of trauma risk and substance abuse disorder.
Why not get a clearer picture of what’s happening on a patient and population basis?
“The challenge for many healthcare organizations that want to participate in new reimbursement models focused on achieving care parity is how to expand healthcare leaders’ view of health equity and SDOH to fully grasp the true reach of this vital data,” Leigh Poland writes in the Journal of AHIMA. “Often overlooked is the fact that healthcare organizations’ coding and revenue cycle management (RCM) departments are already aggregating valuable information that can ultimately help identify and better understand inequities in care delivery and inform initiatives to improve health equity across their patient populations.”
Or, perhaps, RCM departments could be aggregating this information.
How Can We Do Better?
Better RCM practices can’t avert every catastrophe, but they’re the foundation for better outcomes, higher-value care, and increased revenue capture. A good place to start is capturing SDOH factors in electronic health records (EHRs) and using Z codes whenever relevant. Z codes are a subset of the ICD (International Classification of Diseases) codes used in for diagnoses, symptoms, and procedures for claims processing.
As of 2019, the five most used Z codes were:
- Z59.0 Homelessness
- Z63.4 Disappearance and death of family member
- Z60.2 Problems related to living alone
- Z59.3 Problems related to living in a residential institution
- Z63.0 Problems in relationship with spouse or partner
“Most used,” it should be noted, is a relative term. Healthcare providers included Z codes for only 1.6% of Medicare fee-for-service claims in 2019. Another study said well under 1% of commercially insured, Medicare Advantage, and Medicaid patients had a Z code in their records.
“Adoption has been limited due to a lack of clarity on who can document a patient’s social needs, absence of operational processes for documenting and coding social needs, and unfamiliarity with Z codes,” says the American Hospital Association. “In addition, coders may need encouragement and support from hospital leaders to collect these codes that were once perceived as a lower priority.“
Return on Investment
Still, no one disputes the positive effects of identifying and addressing SDOH.
For example, fresh food education programs for diabetes patients who’d been eating poorly reduced symptoms (and costs) and improved quality of life for Geisinger Health patients. A University of Illinois Hospital housing program lowered healthcare costs for homeless patients by 18% or more.
By improving RCM, many behavioral health executives can easily seize opportunities to reduce missed appointments, engage helpful third parties, reduce readmissions, and improve follow-up.
Where to Go From Here
The Centers for Medicare & Medicaid Services (CMS) lay out 5 steps for using Z codes:
- Collect SDOH data. Any member of a care team can collect SDOH data at intake with health risk assessments, screening tools, conversations, or self-reporting.
- Document SDOH data. Record SDOH information in an EHR’s diagnosis, history, and/or provider notes. Supporting data should be retained as well.
- Map SDOH to Z codes. EHRs should be configured to simplify and/or automate the assignment of Z codes to reported conditions. Invest in EHRs that facilitate data collection and coding. Half of organizations surveyed by AHIMA in 2020 lack SDOH fields in their EHRs.
- Use SDOH Z code data. Identify unmet needs and consider SDOH throughout care, services, follow up and discharge planning. Establish triggers to refer patients to social services, and track those engagements. Only 17% have triggers if an SDOH data is entered, according to AHIMA.
- Report SDOH/Z code findings. Include data and analysis in reports for executives and boards to inform value-based care opportunities. Share findings with appropriate social service organizations and health plans. Consider developing a Disparities Impact Statement.
It is widely understood that external factors affect health and health equity. The challenge is understanding the issues, engineering the solutions, and documenting the returns—both in terms of outcomes and costs.
The first step is capturing the data. Data drives solutions.
Khalid Al-Maskari is founder and CEO of Health Information Management Systems (HiMS).
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
References
ICD-10-CM Coding for social determinants of health. American Hospital Association; 2018.
