Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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AS: Summary
AS: Summary
Pages 109-124
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and other social risk factors could be accounted for in Medicare payment and quality programs. The IOM convened an ad hoc committee to conduct a series of five reports related to this task, of which this is the first report.
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2 POTENTIAL UNINTENDED CONSEQUENCES OF VALUE-BASED PAYMENT ON VULNERABLE POPULATIONS AND HEALTH DISPARITIES Improving Value-Based Payment to Address Unintended Consequences While the impact of VBP strategies on providers serving vulnerable populations and on health disparities continues to be monitored both u nder Medicare and more widely, and because more VBP programs are 1 The committee included Medicare Part C and Part D because the study sponsor, the Ofice of the Assistant Secretary for Planning and Evaluation of the Department of Health f and Human Services, included them as relevant payment models in its presentation to the committee at the first meeting (Epstein, 2015) , and thus the program is of interest to them.
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Critics of including social factors in risk adjustment argue that what may appear as differences by social groups may be genuinely attributed to quality differences and not the social factors themselves. In this case adjusting for the social factor would obscure genuine disparities and make it more difficult to hold those providing lower-quality care accountable (Jha and Zaslavsky, 2014; Kertesz, 2014; Krumholz and Bernheim, 2014; O'Kane, 2015)
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In light of this debate, two expert panels have previously examined whether to include social risk factors in risk adjustment for Medicare payment models and offered recommendations. In its June 2013 Report to the Congress, the Medicare Payment Advisory Commission (MedPAC)
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q The statement of task for this report includes several key words that drove the committee's work. The task refers to identifying "SES factors" that "have been shown" to "impact" "health outcomes" of "Medicare beneficiaries." This project is intended to provide very practical and targeted input to HHS and Congress as they consider whether to adjust Medicare payment programs for social risk factors.
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Additionally, Medicare coverage and the measures used to assess health care quality and outcomes do not differ for Medicare beneficiaries by origin of entitlement, except for certain measures of ESRD care and outcomes, and thus the health outcomes in the framework are also equally applicable. Current Medicare quality measures fall within each of the domains embraced by the committee in the expanded definition of "health outcomes." Table AS-1 contains examples of Medicare quality measures currently in use in each of the health care use and outcome domains embraced by the committee in the expanded definition of "health outcomes." COMMITTEE PROCESS AND OVERVIEW OF THIS REPORT The committee comprises expertise in health disparities, social determinants of health, risk adjustment, Medicare programs, health care quality, health system administration, clinical medicine, and health services research.
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FIGURE AS-1 Conceptual framework of social risk factors for health care use, outcomes, and cost. 115 NOTE: This conceptual framework illustrates primary hypothesized conceptual relationships.
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• Central line-acquired bloodstream infection • Catheter-acquired urinary tract infection • Surgical site infection • Incidence of major falls for post-acute care patients Patient Experience • Communication with nurses • Communication with doctors • Getting timely appointments, care, and information • Getting information from Part D drug plan • Helpful, courteous, and respectful office staff • Responsiveness of hospital staff • Care coordination • Pain management • Communication about medications • Cleanliness and quietness • Overall rating of hospital • Rating of Medicare Advantage health plan NOTE: AHRQ = Agency for Healthcare Research and Quality; AMI = acute myocardial infarction; COPD = chronic obstructive pulmonary disease.
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DEFINITIONS AND FINDINGS FROM THE LITERATURE SEARCH In this section, the committee defines each of the five social factor domains, as well as health literacy, and summarizes the results of the lit erature search linking effects of each domain on health care outcomes and quality measures. Socioeconomic Position Socioeconomic position (SEP)
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• The committee identified literature indicating that education may influence health care utilization, health outcomes, and patient experience. • The committee identified literature indicating that occupation may influence health care utilization, health outcomes, and patient experience.
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• The committee identified literature indicating that language may influence health care utilization, clinical processes of care, health outcomes, and patient experience. • The committee identified literature indicating that nativity may influence clinical processes of care and patient experience.
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The committee made the following findings: • The committee identified literature indicating that marital status may influence health care utilization, clinical processes of care, costs, health outcomes, and patient experience. • The committee identified literature indicating that social support may influence heath care utilization, clinical processes of care, health outcomes, and patient experience.
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. The committee made the following finding: • The committee identified literature indicating that health literacy may influence health care utilization, clinical processes of care, cost, and patient experience.
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2015. Accounting for socioeconomic status in Medicare payment programs: ASPE's work under the IMPACT Act.
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MedPAC (Medicare Payment Advisory Commission)
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2010. Race, socioeconomic status, and health: Complexities, ongoing challenges, and research opportunities.
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