CMS Moves Closer to Accountable Care Goals with 2025 ACO Initiatives

January 22, 2025acoNo CommentsData, data collection, health data, health disparties, health equity, health IT, healthcare data, SDOH, social determinants of health, standardized data collection

CMS has made substantial progress on its goal for all people with Traditional Medicare to be in a care relationship with accountability for quality and total cost of care by 2030. As of January 2025, 53.4% of people with Traditional (fee-for-service) Medicare are in an accountable care relationship with a provider. This represents more than…

Generative AI IDs social determinants in EHR notes: Mass General Brigham

January 10, 2024acoAI, Artificial Intelligence, EHR, SDOH, social determinants of health

Generative artificial intelligence can identify social determinants of health within EHR notes, accurately and without bias, determining which patients might need extra support, according to Somerville, Mass.-based Mass General Brigham. The health system’s researchers fine-tuned large language models to automatically extract information about social determinants — factors such as housing, employment and family status that…

CMS Approves New York’s Medicaid Waiver to Address SDOH

January 9, 2024acoMedicaid, SDOH

The Centers for Medicare & Medicaid Services (CMS) has approved New York state’s amendment of its ongoing Medicaid transformation efforts to allow the state to advance health equity, support the delivery of health-related social needs (HRSN) services, and promote workforce development. The state said the waiver would enable New York to invest nearly $6 billion…

Study identifies barriers to SDoH screening in primary care

December 14, 2023acoAWV, Preventive Medicine, Primary Care, SDOH

Researchers from the University of South Carolina School of Medicine and Arnold School of Public Health recently conducted a study to determine what factors may interfere with patients completing SDoH screenings with their primary care providers. Though more and more health systems have recognized the impacts of nonclinical factors, such as food, housing, and transportation,…

How Will CMS’S V28 HCC Model Impact RAF Scores?

October 25, 2023acoNo CommentsRural, SDOH, SNF

The Centers for Medicare & Medicaid Services (CMS) introduced the Risk Adjustment Factor (RAF) model in 2004, which was designed to estimate future healthcare costs for patients. RAF scores are a critical component of value-based care, as they help predict healthcare resource utilization while adjusting for quality and costs for patients. With the introduction of the v28 HCC…

Study links readmissions to discharge process: 6 takeaways

July 19, 2023acoNo CommentsAll of Us, National Institutes of Health, NIH, SDOH, social determinants of health

Patients who have had vascular surgeries are often readmitted to the hospital for a variety of reasons — often preventable — more often than patients who undergo different types of surgeries. These readmissions could be largely avoided if other aspects of the discharge process were improved, according to research led by the University of Missouri in Columbia….

Policy guidance offers strategies to shift to value-based health care and payment

July 10, 2023acoAmerican Heart Association, digital health, health equity, SDOH

The American Heart Association, a global force for longer, healthier lives for all, is advocating for a shift away from the current health care payment system in the U.S., which is primarily based on fee-for-service, to a value-based payment (VBP) system. A VBP system is person-centered, equitable, coordinated and seeks to improve outcomes and experiences…

How NorthShore Uses AI, NLP to Tackle SDOH in the Emergency Department

June 14, 2023acoAI, health disparities, SDOH

Identifying and tackling social determinants of health (SDOH) are crucial aspects of any health equity strategy. But establishing how best to capture patients’ SDOH needs and develop interventions in the clinical setting remains a significant challenge for many healthcare organizations. The United States Department of Health and Human Services (HHS) defines SDOH as “the conditions in the…

CMMI releases three new models aimed at lower generic, novel drug costs

February 14, 2023acoACO care teams, ACO participation, CMMI, CMMS, group practice, MSSP, SDOA, SDOH, SDOHY

The Biden administration rolled out three new payment models intended to lower drug costs, including new Medicare coverage options for drugs cleared under accelerated approval. The release of the three models on Tuesday is in response to an executive order President Biden delivered last year calling for the federal government to search for ways to…

Understanding Education as a Social Determinant of Health

December 27, 2022acoeducation, food insecurity, patient access, racial disparities, risk modeling, SDOH

Education is a critical social determinant of health, largely because of its outsized impact on income and therefore other SDOH. There’s some clear-cut evidence underscoring the impact education has on overall health and well-being. In 2021, researchers published in PNAS that folks with higher educational attainment tend to live longer. Adults with a bachelor’s degree are expected…

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