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Join the RISE team as we chat with industry leaders and explore ever-changing policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health. Produced by RISE, the number one source for information on all things Medicare Advantage.
RISE Radio
Episode 16: Ciox Health’s Lyle Mioduszewski on SDoH, Z codes, and use of member data to close gaps, reduce costs, and optimize utilization
Lyle Mioduszewski, vice president of population health and payer growth for Ciox Health, is our guest for the latest episode of RISE Radio.
In this 26-minute podcast, Mioduszewski discusses social determinants of health (SDoH), data collection and sharing, and best practices for capturing SDoH codes in the medical record.
About Lyle Mioduszewski
Lyle Mioduszewski is vice president of population health and payer growth for Ciox Health, where he works with risk-bearing entities to understand the utility of social determinants of health data factors, with the goal of improved and equitable outcomes for all individuals. With 20 years of experience throughout the health care continuum, Lyle has clinical expertise in emergency and trauma nursing of adults and pediatric populations, as well as cardiac catheterization and electrophysiology nursing. Lyle has been a leader in the health information technology and medical device industries with previous companies, including McKesson Corporation, PointClickCare (Collective Medical), and Zoll Medical. He is passionate about advancing value-based care modalities, augmenting processes relative to varying health literacies, care collaboration, interoperability, and influencing an end to the opioid epidemic using innovative technologies.
About Ciox Health
Ciox Health, a Datavant company, provides leading clinical data technology that empowers greater health by unlocking the potential of data in medical records. The company leverages a ubiquitous network of clinical data connections to connect health care decision-makers simply and securely with the data and hidden insights in patient medical records. Ciox helps customers connect, control, and comply in solving last mile challenges in clinical interoperability. Supporting a range of connectivity needs including risk adjustment, research to revenue cycle, Ciox’s solutions include clinical data acquisition, release of information, and coding.
Hello and welcome to the latest episode of RISE Radio. I'm your host, Ilene MacDonald, the editorial director of RISE. Today's episode will focus on the business side of social determinants of health, which are the social and environmental factors that impact health outcomes. These are the conditions and the places where people live and learn and work. Some reports say they account for as much as 80% of health outcomes.
Ilene MacDonald:The health care industry has been paying attention to these social drivers for years, but the impact of them truly came into focus during COVID, when we saw disparities in care and outcomes across certain racial and ethnic groups. To help us sort through what organizations need to be doing about social determinants of health, data collection and sharing and best practices for capturing SDoH codes in the medical record, my guest today is Lyle Mioduszewski, vice president of population health and payer growth for Ciox Health, where he works with risk-bearing entities to understand the utility of social determinants of health data factors, with the goal of improved and equitable outcomes for all individuals. is a Datavant company that provides leading clinical data technology that empowers greater health by unlocking the potential of data in medical records. Welcome, Lyle, thank you for joining me today.
Lyle Mioduszewski :Hey, Ilene, thanks for having me. I think you may have said my name better than I can. Thanks for having me on.
Ilene MacDonald:I know I gave kind of a reader's digest view of SDoH in the beginning. Is there anything you think the listeners should know before we sort of delve into what organizations should be doing now?
Lyle Mioduszewski :Yeah, I mean the idea here is that social determinants of health isn't something that we created recently, it's not something that even has just started to be addressed, maybe at scale at the national level and through policy, but we've had medical social workers for a really long time. We've been looking at the social influences on health and health decline for a very long time, and so I think what happened and really what's put this into the spotlight and created some interest in funding activities and business activities, is off the backs of Executive Order 13985, I'm sorry, 19385. And this was the first Executive Order that came out of the Biden administration January 2021 focused around racial equity and supporting underserved communities, and this gave us the guidelines of things that have come after that, such as ACO Reach, the in lieu of services guidelines around Medicaid and how we take care of these populations with non-medical interventions, and even just recently here announced over the last couple weeks the Making Care Primary model that has equitable considerations for care, and so again, I think that this is the hot button topic.
Lyle Mioduszewski :It needs a lot more funding and we can get into that, but that's the general idea here, and those of us that have a clinical experience, we know that the social situations and where you spend the majority of your life. I don't know about you, but 99.99% of my life is not spent in a hospital bed, it's just in my social life, and that's what really contributes to how healthy of a person I am, understanding that there's genetic influences and many other things, but your social situation and where you've grown up and lived and thrived, or lack thereof, is precipitating what kind of health you may be able to experience and achieve.
Ilene MacDonald:And that can even vary from neighborhood to neighborhood, right?, depending on where your ZIP code is.
Lyle Mioduszewski :Yeah, it's a good point and that's actually changing. You know, there's a lot of emphasis and there has been a lot of emphasis over the last few years on things like area deprivation index and so if you're not familiar with that calculation, it looks at things like median home income and value of the home and and what you look like if you are in a certain zipZIP code, or even even more granular, at the census block. I think we're coming to a reflection point here where we realize that's good for population health analytics, but when we're starting to look at intervening on individuals and and how we can better their health at the individual level, we need to get a little bit more granular than an area deprivation index or ZIP code level thinking. And a good example of that is just the gentrification that's happening in major cities across the country of the last 20 years.
Lyle Mioduszewski :You know, typically we could say, hey, i lean lives on on this certain block or in this certain ZIP code And generally this is an underserved community. She likely needs a ton of help and and that might not be the case for you, i lean, you might live in the high rise on the corner When everybody else and that that that block is in government subsidized housing and so it can go both ways. We see, if you're looking at just housing and access and transportation and things, the expansion of section eight housing into other communities, and so you know the way that I think about this and from a business and data perspective, is, it's everywhere and we really need to be looking more granularly, not just at the person level. We need to be looking at the numbers of latency of that data at the person level. We have access to getting information so fast now. I think that's the next frontier of social determinants of health as a business.
Ilene MacDonald:All right. Well, let's sort of do a little deep and some of the things that you've just mentioned, because it's a lot. So I know and NCQA and CMS has put out some new requirements, so maybe the new models and different things. So what should we be thinking about right now?
Lyle Mioduszewski :Gosh, that's a that's a good question. There's so many answers to it. I think the you know, talking to providers and payers alike, it seems that the mandates that are out right now, the things that are driving quality and Star ratings, are front and center, and so what that means is organizations are looking to fulfill the HEDIS(R) requirements that say we want to see how many patients you're screening, how many individuals are being screened for health related social needs in a standardized format, and then how are you intervening on those people? And so those are the measurements being taken right now. I think it's a good precursor to understanding how they correlate to health outcomes.
Lyle Mioduszewski :We're not there yet, but, again, you have to start somewhere, and so, at the plan level, at the population health level, we are starting to see standardized screenings take place, and the interventions are variable, and a lot of that just has to come down to the funding right. A lot of this works being done, maybe not at the point of care, but to referrals out to community based organizations. If we want to talk about the problems in that the interoperability, or lack thereof, between health care and how publicly funded organizations operated is an issue. But but we're moving into that direction and I think we see that as one of the next stages of development industry is how do we make that intervention mandate component synchronous with the work that's being done with the community based organizations, and probably better than that. So I think it's a component of what the health plan does as a core service for their members.
Ilene MacDonald:It's a lot. I know that part of the problem that I've been hearing when I've gone to conferences and interviewed different people is that a patient may report like a social determinant health type thing. Maybe it makes it into the medical record, maybe it doesn't, but it's not always great documentation or enough information. What are you advising for maybe enhancing that clinical data?
Lyle Mioduszewski :That's a good one. So I think it is happening With regard to self reporting of data. There's a couple of things to consider here. I know that through my chart, which is an Epic service that my primary care physician uses, I've been pushed social determinants of health surveys, and there's a little bit of an odd feeling there when you haven't had a history of your provider asking that type of information, especially if it's not in person and relevant to why I'm visiting the physician. But hey, you just asked me about my whole social life, and so there's a couple considerations to make there. One is the realization of one's own social situation and disparities that might exist against the rest of the population said differently, if I am an elderly, individual might not understand that I'm financially insecure or I'm not eating appropriate foods or might not be able to afford appropriate foods to my diseases and my overall health, and so that's one consideration to make is the subjective nature of surveying. Again to the first thing I said getting completeness in that is going to be an issue.
Lyle Mioduszewski :Not everybody wants to give up this information freely. It's unstructured and that that's a really big component here. Oftentimes the conversation that does end up happening at the point of care. When I have a good enough report with my physician and they asked to write questions in a motivational way, i might give up some information such as gosh, that drug you prescribed for me. It's outside of my means, i have a really hard time getting to the pharmacy or whatever that issue might be. At this point in the game and this is a long-winded response but I think it's so important that at this point the game the providers aren't motivated economically to document that information, right? There's no, I say there's no coding, but there is coding. There's no reimbursement tied to that coding. And so, as we look at the ICD 10 codes, people who are familiar with the space understand that there are Z codes and a subsection of those Z codes, specifically 55 through 65, are aligned to social determinants and that's how you're going to get to the health influencing your health outcomes. Oftentimes the information related to the provider isn't making it into the chart in a structured or or I should say structured, standardized format, because there's no reimbursement again tied to that for the provider.
Lyle Mioduszewski :As we look at completeness across the entire continuum, it's you know different figures, but somewhere between 1 and 3% of the time providers are actually documenting this. You don't really know why. They don't have any rationale to do so. There's a couple states where there are bonus payments made to the, to the managed care organization specifically, or marketplace plans to have the provider document. That might be some of the influence.
Lyle Mioduszewski :What is happening and it needs to be recognized is health care providers your, your doctor, your PA, your NP, even people on the clinical care team that aren't at that highest level of operating.
Lyle Mioduszewski :But nurses, social workers, therapists, social information is making it into the chart in unstructured format, meeting into progress notes and nurses notes, procedural notes and things like that, and I think that's significant.
Lyle Mioduszewski :I think that when a provider takes the time to author something about your social well-being or lack thereof and put it into their note, they think that that has to do with how healthy or unhealthy you are, and so our access to that information in near real time is starting to change.
Lyle Mioduszewski :So it should have changed a long time ago with the proliferation of the electronic health record, but we're still in an area of uncertainty with interoperability, and as we get more advanced, I think there becomes an opportunity here to harvest some of that information, put it through the coding, procurement, and operational mechanisms that exist today and maybe even layer some technology on top of it, like natural language processing, optical character recognition over handwritten notes and qualifying, quantifying some of those social situations for use outside of what we normally do with codes Today.
Lyle Mioduszewski :We take codes, we reimburse on them, we risk adjust on them. There's lots of thoughts on how we can do that with social information, but as far as utilizing it to advance care and mitigate more morbidity or morbidity of disease, there's so much more we can be doing with it, and so we can take that 1 to 3% of completeness in social Z codes and probably bump it up to 30 or 40% on most of the population And again get us from that level of thinking where everyone who lives in ZIP code A looks like everyone else in ZIP code A. But no, we're all. We all have a different situation and there's a more objective way to think about this.
Ilene MacDonald:So it's a lot, and you mentioned that part of the problem is their lack of the reimbursement. So what is sort of the future with that? Are we moving to that? Do you see that in the near future.
Lyle Mioduszewski :That question is is hard to answer and it's the root of it is in new responsibility. Is it to create a fair and just health care system? The issues of inequality and health equals wealth is rooted in the political and structural systems of our country. The beneficiaries of addressing social determinants of health for the advancement of health outcomes are twofold, it's the patient And it's the payer, right, the person who's taking financial risk of that person And in the financial interest of the payer, to try to create some sort of equitable intervention to bring that person to achieve the highest level of health that they can across an entire population.
Lyle Mioduszewski :That is no small feat, and changing the structural systems of our society is also no small feat. And so to understand where reimbursement happens, the taxpayers have to agree. The people making those decisions have to understand that your constituents agree and maybe they don't, i don't know that for government lines of business, we're going to fund it. We're going to fund social supports, non medical interventions that are going to bring everybody to a baseline level of expected health. There's questions here about is this socialized medicine? So the reality is is that in our country the lowest tier of health care is really bad? The outcomes in this country for a first world country, our, our, our lowest tier of health care. Our outcomes are worse than many third world countries, and so how do we bring that tier of health care up to some sort of a median standard and make wealth as health less of a thing.
Ilene MacDonald:At least with the providers I've spoken to less reimbursement, more quality of care. They went into the business to make sure that their patients are well, so that is one of the incentives. To encourage that by documenting this information and sharing it, and connecting, maybe, their patients to social services
Lyle Mioduszewski :It's a good point. I think what you're hinting on a little bit is that there's a maybe a value-based care play here. I haven't been an expert in referring people to organizations that can help them with health related social needs or there isn't a lot of interoperability between the health care continuum, the social care continuum.
Lyle Mioduszewski :But I want to do it and I need the right funding mechanisms to do it, and so there's a little bit of work that has to be figured out there.
Lyle Mioduszewski :But I think it's generally realized that if I'm taking a capitated payment on a person's life and I improve that 80% component that makes up the health outcomes, my capitation from a business perspective is the margin there is probably going to expand and it's the right thing to do. Again, it seems to be that data interoperability and philanthropic funding are the two issues that are happening with making that a reality. I think in some instances and some geographies it is happening, but it's not happening at scale. We're seeing some of the payers, some of the large physician organizations that take risk, do developments in housing. That's a Herculean effort. What we're not seeing is anything at scale, and so I don't know what that looks like, but it seems to be if we want to see value-based care as the modality to get this achieved. We move the data in near real time and then we have to work on the backend, and a lot of that's funding and a lot of that's politics.
Ilene MacDonald:Another thing that I've been hearing from people is that their organizations themselves have the data siloed, so one department might not be speaking to another, so like, maybe, risk and quality, they're not sharing that information, so it almost seems like before you can share it with community-based organizations or with the plans, that you need to be sharing within your own organization. Maybe that's too simplistic, but what are your thoughts on that and where can we start to make that happen?
Lyle Mioduszewski :Shocking topic we're not sharing data across our own organization. I think that it that's the truth, and so I hinted on this a little bit earlier that there are already procurement mechanisms in place and pathways where the data is being ingested and maybe not realized today. And so, as I think about it, as we shift into the HEDIS(R), ECDS model, which are digital measures and where you need to be collecting real-time medical records versus looking back to last year's stuff, there's an opportunity for the procurement pathway of risk and quality to look across your organization and say who's working on social determinants of health, what kind of data are you using and what does real-time social data mean to you? Because we think we can get it and we probably don't have to pay a lot more for it. Meaning I'm retrieving medical information as, let's say, the risk adjustment department.
Lyle Mioduszewski :I'm looking for diagnoses, codes that are related to hierarchical conditions. That's really all I care about. But as I'm doing that work, i can quantify and qualify social situations into SDoH codes, and so, if I can do that, it costs me a lot of money to retrieve a medical record and it costs me a lot of money to code a medical record. Does it cost me that much more to get the social information out of it, because the reality is the folks on the care management team and the member engagement and the SDOH team they don't have the budget today to go procure the medical record and code the medical record, and so I think that the opportunity is to work across the organization, and how we get that done I'd love to find out.
Ilene MacDonald:Is there anything I haven't asked you? I mean, it's such a big topic that I'm sure that we could speak on it for hours. But is there anything that you think on data collection, data sharing, on interoperability, whatever it is that organizations for their sort of best strategies from going forward from today, what they should be thinking about, what they should be doing?
Lyle Mioduszewski :You know it's an interesting question because we don't know what we don't know. But what I do know and I hinted on this a little bit is as we move into more of a forced digital ecosystem and specifically around quality and NCQA with ECDS, we should think about what the motivations to do that were and what the benefits are to us as consumers of health care. And what I mean by that is the first part of digitizing health measures was to ensure that we were getting a complete sample that had their care gaps closed across everyone and you're going to be measured on that now. Right? Previously, if you're unfamiliar, HEDIS(R) measures were looked at from a sample set And so we can use the first HEDIS(R) measure that will be going to digital next year for measurement.
Lyle Mioduszewski :Colorectal cancer screening. There's a certain population within the health plan that meets criteria and needs to have it done. In the old model or the hybrid model today there's a sample set taken of 411 selected patients. Depending on how many of those were completed on the measure, they would extrapolate that out to the rest of the population and your payment was based on that as a payer. It left a ton of people in the denominator of that measure without a colorectal screening and a lot of those people didn't get their screening because of social determinants of health.
Lyle Mioduszewski :What happens here is that now all populations need that fall within that measure, everybody in that denominator needs to have a colorectal screening, and some of those people are going to need to be influenced and helped and assisted in a different way than ever before, because they actually matter now. So that was the first goal was to make sure that all of these individuals within a given measure are being accounted for and the plan was being held responsible to, and I think that's really important. The second part of it is making the information gathered through the measure accessible at the point of care, so it's bidirectional. So now the health plan has collected that information. And as I sit in front of my provider, they have the information gathered from that, they understand not only what the results of it were and if there's intervention needed, but if it didn't happen, and now there's another chance to intervene on that individual.
Lyle Mioduszewski :And so, as I'm thinking forward, what I see is a large lack of planning around ECDS and furthermore, not just capturing it and hitting the marks and making sure you get paid, and that's, of course, what everybody their initial work is toward. But what's the meaning of and you never hear this, you never hear anyone talk about what's the meaning behind this? And I think those are the two meanings. If we address the social determinants of health and start thinking about those within that workflow now, as we're planning, it's going to take us to a new level of intervening on social determinants of health and something meaningful that's actually reimbursed.
Ilene MacDonald:Well, it seems like we have a lot of policymakers wanting us to move in that direction, so that's very hopeful. Before we close, I wonder if there are any final thoughts, any other things that you would recommend our listeners think about as they go forward.
Lyle Mioduszewski :That's a good question.
Lyle Mioduszewski :The main thing is that again without turning this into a complete plug, real-time clinical data across EMRs, across data types, standard types is becoming more readily available.
Lyle Mioduszewski :Most of our folks that we engage with both the risk-bring provider and payer side, there are used to four-month turnaround times data that is often behind claims data. What we want people to start to think about is how do I get in front of the claims information? How do I get something that happened two weeks ago in my hands next week? A lot of folks are not realizing that the capabilities are there. There's companies offering and selling their digital network, inclusive of ours, and the access to that for the right use cases, as long as they fall underneath TPO framework. We're interested in talking with any organization that wants to access real-time clinical data in a digital format or even old-school format, and work together on how to innovate and do some of the things that we talked about here today not just getting the data submitting to CMS, but what else can we do with it or on the plan? How do we advance our nation's health care outcomes? They're terrible. How do we use data to do that?
Ilene MacDonald:I hope that in a few years we can talk again and we can see how far we've come since today's conversation. Hopefully it won't take as long as I think you're implying that it might be. Thank you, Lyle. I really enjoyed the conversation today. Appreciate your time.
Lyle Mioduszewski :That'd be cool. Thanks, Ilene.