Social Risk Indices In The Commercial Market: Payer & Provider Perspectives

Commercial healthcare & social risk

RTI Health Advance recently sponsored a market assessment project with a group of senior-level students from the University of North Carolina (UNC) Gillings School of Global Public Health.

The objective of the project was to determine how healthcare payers and providers in the commercial market utilize social risk adjustment tools to advance health equity. Among the tools discussed was a proprietary tool, RTI Rarity™, an artificially intelligent tool that measures and analyzes social determinants of health to produce a local social inequity index (LSI) based on 200+ area-level variables across 10 domains at the Census, ZIP code, and county levels.

Project goals

The student team had 3 primary objectives:

1. First, understand the RTI Rarity™ tool and compare it to similar tools in the current healthcare market.
2. Second, understand current and future health equity goals for payers and providers.
3. Finally, develop recommendations for how social risk tools can be used to advance health equity in commercial healthcare organizations.

What is health equity?

The goal of health equity is to ensure that every person has an equal opportunity to achieve good health. The Centers for Disease Control and Prevention (CDC) define health equity as, “the state in which everyone has a fair and just opportunity to attain their highest level of health."

Helping healthcare payers and providers to achieve their health equity goals requires a multifaceted approach that addresses a wide range of domains including fair access, relationship-driven continuity, care coordination, and individual social determinants of health. Social determinants of health, also referred to as drivers of health, describe non-clinical factors that affect the health of individuals and communities, such as access to transportation, access to nutritious food, employment opportunities, air and water quality, and housing stability.

What are social risk indices?

Social risk indices, also called social deprivation indices, are composite measures of social risk factors that predict health outcomes for given small-area designations. In the US, the major examples of these tools include the CDC's Social Vulnerability Index (SVI), the University of Wisconsin's Area Deprivation Index (ADI), and the Robert Graham Center's Social Deprivation Index (SDI). There are also many other indices. RTI International offers the aforementioned proprietary social risk index tool, RTI Rarity™, which draws on a variety of public and private data inputs and advanced artificial intelligence models to generate a local LSI. Benchmarked against the other major US social risk indices, LSI scores demonstrate greater predictive power for life expectancy at birth than SVI, ADI, and SDI.

While social risk indices can be powerful tools in predicting localized social inequity, they become even more useful when paired with individual-level data. Through a combination of indices and individual data, predictive models can more accurately describe patient health risks and lead to more tailored healthcare delivery.

Method used to understand social risk index

To better understand the landscape of social risk index tools, we first conducted a rapid literature review of relevant publications from the US. Second, we reached out via email and phone to a variety of US-based health services and population health researchers to gather expert perspectives on social risk indices and their use cases. Finally, we conducted 5 semi-structured interviews with payers and providers to understand their experience with social risk adjustment tools and current health equity goals. The research team interviewed 3 mid-size insurance companies and 2 large healthcare provider organizations. Interview notes were coded using a grounded approach to arrive at key themes.

Current healthcare industry trends

The viability of social risk indices for payment adjustment has been successfully demonstrated in a number of individual states and is being investigated in new models through the Center for Medicare & Medicaid Innovation (CMMI). However, experts and industry leaders alike report that payment adjustment based on social risk indices has not yet appeared among commercial payers. Some questions remain about whether commercial payers have a large enough percentage of their member pool with unmet social needs to benefit from social risk-targeted payment schemes.

Despite this lack of deprivation-adjusted payment, social risk indices have proven helpful in other use cases for the commercial market, including through adjusting predictive models for specific health outcomes. Payers and providers both described using area-based social risk indices to account for non-clinical factors and uncollected individual data in their own predictive models. While the most popular indices (ADI, SVI, SDI, etc.) came up repeatedly in interviews, some organizations also reported using less-common indices specific to certain outcomes of interest. And although area-based indices can be useful for understanding high-level inequity, interviewees also reported that individual-level data is most helpful for uncovering disparities in their specific patient/member pools.

Slow uptake in the use of social risk indices

In the application of social risk indices to payment models, most commercial payers have not adopted any adjustment measures. However, many report investigating this as a route to addressing social determinants of health in the future. The social risk-adjusted models in demonstration by CMMI are the leading edge of innovation for this application of indices. Current value-based care contracts in the commercial payer market largely use metrics recommended by CMS. As a result of reimbursement, commercial providers largely rely on the metrics used by their relevant payers.

The team discovered that payers and providers have a strong interest in addressing health equity issues but may not be fully aware of the potential use of social risk indexing tools. In response to this, the student health policy management team recommended that RTI Health Advance prioritize data collection assistance services, assist organizations with home-grown analytics, help providers understand payer metrics and adjustment models, move beyond measurement and analysis into action, and work with agencies and organizations to standardize social risk indices.

How commercial healthcare organizations can use social risk indices to advance health equity

Through our research and analysis, we found multiple areas of opportunity for social risk indices to be applied to open health equity problems in the commercial health care industry. Interviews with payers and providers revealed that they are facing challenges in effectively navigating data, with many being in the infancy stages of utilizing social risk indices.

From our findings, we present the following recommendations for future use of social risk indices among commercial healthcare organizations:

• Develop robust, standardized data collection and management practices
• Where data gaps exist, use area-based indices to approximate individual risk
• Invest in analytics capabilities to create home-grown predictive models adjusted by social risk factors
• Incorporate equity measures into metrics used for value-based care contracts
• Move to action by aligning resource allocation with social risk

Overall, the UNC capstone team's research and analysis highlighted the importance of social risk tools in promoting health equity when applied to payment allocation, predictive modeling, and social need intervention. The team's recommendations will aid RTI Health Advance in advising clients to make more impactful decisions when it comes to effectively utilizing these tools.

This project is the work of the following graduates of the UNC Gillings School of Global Public Health: Jessica Uba, (Sherry) Jiamin Ma, Ethan Phillips, and Chloe Stiles.