The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians

Abstract

Policy Points One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs. At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low-income populations, but not exposure to value-based payment. Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity.

Context: One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks.

Methods: We used the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices' participation in value-based payment models; and (3) measures of practices' capacity for innovation. We used multivariate regression models to examine predictors of social risk screening.

Findings: On average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices' overall exposure to value-based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices' capacity for innovation.

Conclusions: Our results indicate that implementation of social risk screening-an initial step in enhancing awareness of social needs in health care-is not associated with overall exposure to value-based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.

Keywords: implementation science; primary care; social determinants of health; social risk screening.

Figure 1

Margin Plots Depicting Adjusted Association of Value‐Based Payment Exposure and Innovation Culture With Social Risk Screening [Color figure can be viewed at wileyonlinelibrary.com] These panels, based on the multivariable analyses presented in Table 2, show adjusted relationships between the number of social needs screened by a physician practice and select variables of interest. Panel A illustrates the nonsignificant relationship between greater exposure to value‐based payment models and social risk screening. Panel B illustrates the significant, positive association between practice scores on the innovation culture scale and social risk screening. Social risk screening also showed a significant, positive relationship with our other three measures of practice capacity for innovation as well, namely, scales measuring barriers to care delivery innovation and advanced health data system capacity, and the single‐item measure of having a system in place to keep up with evidence.

Figure 2

Adjusted Association of Participation in Specific Value‐Based Payment Models With Number of Social Risks Screened [Color figure can be viewed at wileyonlinelibrary.com] Abbreviation: ACO, accountable care organization. This figure depicts associations between individual payment reforms and number of social risks screened. Dots represent the estimated coefficient for each payment reform, with lines representing 95% confidence intervals. Only the coefficients for participation in individual payment reforms are shown here, but the fully adjusted and weighted regression model included practice ownership, size, region, Federally Qualified Health Center status, Medicaid revenue, anticipated accountable care in five years, and scales for innovation culture, innovation barriers, having a system for evidence, and advanced data system capacity.