SDoH Recognized in the 2023 IPPS Final Rule

Some SDoH conditions are more likely than other to be impactful on healthcare consumption.

The Centers for Medicare & Medicaid Services (CMS) unveiled the fiscal year (FY) FY 2023 Inpatient Prospective Payment System (IPPS) Final Rule in early August.

The agency included a discussion about Social Determinants of Health (SDoH), defined as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health functioning, and quality-of-life outcomes and risks.” It is recognized that SDoH “influence an individual’s health status and can contribute to wide health disparities and inequities.”

They can be important risk factors in developing medical conditions like heart disease, diabetes, and obesity.

There is, however, a fundamental catch-22 regarding the documentation, coding, and recording of SDoH. In the big healthcare picture, they are very influential, but they may not be thought to affect the resource consumption during a hospital admission.

So why should hospitals invest the time and resources to capture SDoH data? But if hospitals don’t capture SDoH codes, we may not be able to identify how prevalent the conditions are in hospitalized patients. If we can’t recognize how frequently they occur and in which patients, we may not be able to appreciate their impact on the hospitalized patient. We can’t tell if those conditions have increased the length of stay or required significant social work or utilization review/case management planning if we are not recording and coding them.

Homelessness is a concrete example of this. It is one of the more commonly reported SDoH codes but it is still believed to be underreported. The Z59.0- category was recently expanded to include sheltered, unsheltered, and unspecified homelessness. Homelessness had been proposed (but tabled) to become a comorbid condition or complication (CC), but the calculation to determine whether it is CC-worthy is being impacted by underreporting of the condition.

The data of SDoH is important to collect for many reasons. There needs to be an incentive or a simple way to collect the data. One of the objections is that there is a limited number of diagnoses which can be entered on a claim, and folks are reluctant to use up some of those precious line-items on non-medical conditions. Comments were also made about the benefit of screening for SDoH if there is no mechanism to make referrals or to connect patients to resources to address their needs. There was also a concern that there may be a stigma associated with SDoH, and patients may be hesitant to share that information.

People are not familiar with all 73.5 thousand ICD-10-CM codes. They likely don’t know all the codes which are housed in the Z55-Z65 categories which comprise the SDoH. I am not sure the hospital personnel need be acquainted with or elicit every SDoH condition.

However, there is a list of SDoH conditions which I think are likely to be more impactful on the healthcare consumption and equity playing field. Here is my list:

• Z55.0 Illiteracy and low-level literacy
• Z56.0 Unemployment, unspecified
• Z57.1 Occupational exposure to radiation
• Z57.31 Occupational exposure to environmental tobacco smoke
• Z57.39 Occupational exposure to other air contaminants
• Z57.4 Occupational exposure to toxic agents in agriculture
• Z57.5 Occupational exposure to toxic agents in other industries
• Z57.6 Occupational exposure to extreme temperature
• Z58.6 Lack of adequate drinking water
• Z59.0- Homelessness
• Z59.41 Food insecurity
• Z59.5 Extreme poverty
• Z59.7 Insufficient social insurance and welfare support
• Z59.81- Housing instability
• Z59.82 Transportation insecurity
• Z59.86 Financial insecurity
• Z60.2 Problems related to living alone
• Z60.4 Social exclusion and rejection
• Z64.0 Problems related to unwanted pregnancy

CMS is still sorting this out, and I will be interested to see where facilities and providers end up landing on collecting SDoH data. I hope they figure out a time-efficient and standardized manner that does not create undue burden.

There may be a benefit not only to the individual patient, but also to the health system in general.

Programming note: Listen to Dr. Erica Remer every Tuesday morning when she cohosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.