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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by Contract No. HHSP233201400020B from the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-39197-9
International Standard Book Number-10: 0-309-39197-0
Document Object Identifier: 10.17226/21914

Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2016 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016. Systems practices for the care of socially at-risk populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Ralph J. Cicerone is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org.

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COMMITTEE ON ACCOUNTING FOR SOCIOECONOMIC STATUS IN MEDICARE PAYMENT PROGRAMS

DONALD M. STEINWACHS (Chair), Professor, Johns Hopkins Bloomberg School of Public Health

JOHN Z. AYANIAN, Alice Hamilton Professor, Director, Institute for Healthcare Policy and Innovation, University of Michigan

CHARLES BAUMGART, Senior Medical Director, xG Health Solutions

MELINDA BUNTIN, Professor and Chair, Department of Health Policy, Vanderbilt University School of Medicine

ANA V. DIEZ ROUX, Dean and Distinguished Professor of Epidemiology, Drexel University School of Public Health

MARC N. ELLIOTT, Senior Principal Researcher, RAND Corporation

JOSÉ J. ESCARCE, Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles

ROBERT FERRER, Dr. John M. Smith, Jr. Professor, Department of Family & Community Medicine, University of Texas Health Science Center at San Antonio

DARRELL J. GASKIN, William C. and Nancy F. Richardson Professor of Health Policy and Director, Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health

MARK D. HAYWARD, Professor of Sociology, Centennial Commission Professor in the Liberal Arts, Faculty Research Associate, Population Research Center, The University of Texas at Austin

JAMES S. JACKSON, Daniel Katz Distinguished University Professor of Psychology, Research Professor, Institute for Social Research, University of Michigan

DANIEL POLSKY, Executive Director, Leonard Davis Institute of Health Economics, University of Pennsylvania

MEREDITH ROSENTHAL, Professor of Health Economics and Policy, Harvard T.H. Chan School of Public Health

ANTHONY SHIH, Executive Vice President, The New York Academy of Medicine

Study Staff

KATHLEEN STRATTON, Study Director

LESLIE Y. KWAN, Associate Program Officer

EMILY VOLLBRECHT, Senior Program Assistant

REBECCA MORGAN, Senior Research Librarian

DORIS ROMERO, Financial Associate

HOPE HARE, Administrative Assistant

ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice

SHARYL NASS, Board Director, Board on Health Care Services

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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by GEORGES C. BENJAMIN, American Public Health Association, and CHARLES E. PHELPS, University of Rochester. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Acknowledgments

Many individuals generously provided case studies to the committee during the course of the deliberations leading to this report. In particular, the committee thanks Susan Hayes, Martha Hostetter, and Douglas McCarthy of The Commonwealth Fund. In addition, the committee extends thanks to Lynne Cuppernull and Howard Shapiro of the Alliance of Community Health Plans, Mark Hamelberg of America’s Health Insurance Plans, Susan Knudson of HealthPartners Minnesota, John Lovelace of the UPMC Health Plan, Sanne Magnan of the Institute for Clinical Systems Improvement, Dana Safran of Blue Cross Blue Shield of Massachusetts, and Bruce Siegel of America’s Essential Hospitals.

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