Social correlates of health not so determinant after all...

I have been reviewing the social risk adjustments under consideration for Medicare payments--Accounting for Social Risk Factors in Medicare Payment: Criteria, Factors, and Methods.

The authors of the 124 page document concisely defined  value-based payments- as quality and risked based incentives including Alternative Payment Models (APMs). Also loosely considered under the model were Medicare Advantage (Part C) and the risk sharing and bonus payment included in Part D.

It seems the noise and profit incentives of medical solutions often diminish findings in support of preventitive strategies. Value-based payment programs are being encouraged to account for social risk factors. Failure to do so underestimates the quality of care provided in socially at risk populations. 

At the same time, because these providers are also
more likely to care for patients who are uninsured or covered by Medicaid, they have historically
been less well funded than providers caring for larger proportions of patients with commercial
insurance that pay more generously for care. If providers disproportionately serving vulnerable
populations are likely to have fewer resources to begin with and care for patients who require
more resources to achieve the same health care outcomes

As described in the framework, the bold lettering indicates measurable indicators for the short term, italics are longer term ideals that may prove informative in developing underlying constructs despite current challenges. The plain text reflect considerable limitations in influencing or measuring these as quantifiable indicators.

There has not been a single health policy meeting in my recent memory where the discussion did not eventually lead to value. How do we define it and better yet, how do we measure it. I featured Nudging Physicians Toward Value: Incentives in the Era of MACRA-Economics in a prior post about APMs and the financial incentives available within the context of managing outcomes and costs in healthcare.

An interesting article from the Economist grabbed my attention today. It was making the rounds on Linkedin although the article is over 4 years old--the findings reported a robust correlation between social hierarchy and health in rhesus monkeys.

​Researchers searched for correlations between social rank and gene expression and observed different levels of gene activity in low-ranking monkeys when compared to higher-ranked individuals.

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The next question was what all these genes actually do. Sure enough the answer, for a substantial fraction of them, was that they regulate aspects of the immune system. In particular, low-status individuals showed high levels of activity in genes associated with the production of various immune-related cells and chemical signalling factors, as well as those to do with inflammation (a general immune response that involves tissue swelling and increased immune-cell activity in the affected area).

​Although the researchers did not explicitly examine the health of their simian charges, chronic, generalised inflammation is a risk factor, in people, for a long list of ailments ranging from heart trouble to Alzheimer's disease.

The actual clinical study is quite the rabbit hole if you are interested in the underlying gene expression mechanisms potentially influenced by social correlates linked to health outcomes--Social environment is associated with gene regulatory variation in the rhesus macaque immune system

The graphic below looks at residual gene expression in PTGS2 (proinflammatory signaling molecule negatively regulated by immunosuppressive glucocorticoids), IL8RB(receptor for proinflammatory cytokine IL8) and NFATC1(associated with the transcriptional response to T-cell stimulation).

Finally, the team investigated the mechanisms behind these differences in gene expression. In keeping with previous work, they found that high- and low-rank individuals showed different levels of responsiveness to a class of hormones called glucocorticoids, which regulate immune-system activity and response to stress. They also found changes in the mix of cells within the animals' immune system itself. But what is new, and intriguing, is that they discovered, for the first time, evidence that a phenomenon called epigenetic change is at work.

Epigenetics—currently one of molecular biology's hottest topics—is a process by which genes are activated or deactivated by the presence or absence of chemical structures called methyl and acetyl groups. Dr Tung and Dr Gilad found that methylation patterns were systematically different in high- and low-ranking animals. Crucially, these changes are generally passed on to the daughter cells produced when a cell divides, and are thus perpetuated throughout an animal's life. To the extent that epigenetic marking is involved in creating social status, then, status may be being maintained by the animal's cells as they replicate.

Thoughtful discussions about content development and outcomes analytics that apply the principles and frameworks of health policy and economics to persistent and perplexing health and health care problems...

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You might also be interested in my collection of short stories in healthcare. They were created from email exchanges and conversations with colleagues. 

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