Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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1 Introduction
1 Introduction
Pages 23-46
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From page 23... ...
. Achieving health equity may require reducing the influence of unfair inequalities in health status by power, wealth, or prestige, which may exist across social groupings owing to social risk factors such as income, race and ethnicity, or gender (Braveman and Gruskin, 2003; IOM, 2001; NASEM, 2016b)
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. In other words, because achieving the same health care outcomes, health status, or health improvements may require remediating deep social inequalities in social risk factors such as inadequate housing or food insecurity, providing equitable health care is unlikely to be sufficient on its own to achieve health equity at the population level (NASEM, 2016b,d)
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. Although the goals of VBP programs are explicitly to improve health care quality and outcomes and to control costs, the focus on health care outcomes provides implicit incentive to address social risk factors that may contribute to poor health care outcomes and to health disparities.
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. Thus, health care organizations that have adopted this broader approach to improving population health not only actively manage the health of their panel population, but they have also begun to intervene on social risk factors "beyond their walls." As described in the committee's second report, some providers are collaborating with social service and public health agencies and community-based organizations to link clinical interventions to social programs such as housing assistance, vocational counseling, legal assistance, and assistance applying for government benefits (NASEM, 2016d)
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For example, if a hospital provides transportation services for patients to overcome barriers to transportation and to improve access to health care services, this does not address problems in the underlying transportation system. Although VBP programs have catalyzed health care providers and plans to address social risk factors in health care delivery through their focus on improving health care outcomes and controlling costs, the role of social risk factors in producing health care outcomes is not reflected in payment under current VBP design.
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One proposal to address the documented harms of the status quo under current VBP is to account for social risk factors in quality measurement and/or payment. Currently, to ensure accurate comparisons, VBP models account for underlying clinical risk factors known to independently drive variation in performance and to differ systematically across providers and therefore could statistically bias measured performance.
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Several studies have found that adding socioeconomic status (SES) and other social risk factors would not substantively change risk adjustments and thus quality rankings ( ernheim B et al., 2016; Blum et al., 2014; Eapen et al., 2015; Keyhani et al., 2014; Martsolf et al., 2016)
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. Relatedly, one study found that, under the Hospital Readmissions Reduction Program, social risk factors explained some but not all of the increased readmission rates seen among safety-net hospitals (Sheingold et al., 2016)
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In the second report, the committee reviewed the performance of providers disproportionately serving socially at-risk populations, discussed drivers of variations in performance, and identified six community-informed and patient-centered systems practices that show promise to improve care for socially at-risk populations. The committee's third report identified social risk factors that could be considered for inclusion in Medicare quality measurement and payment, criteria to identify these factors, and methods to account for them in ways that can promote health equity and improve care for all patients.
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that could S potentially be used to determine whether an SES factor or other social factor should be accounted for in Medicare quality, resource use, or other measures used in Medicare payment programs. • dentify SES factors or other social factors that could be incorporated into I quality, resource use, or other measures used in Medicare payment programs.
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Identifying Social Risk Factors and a Conceptual Framework The committee's first report, Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors, presented a conceptual framework illustrating the primary hypothesized relationships between five domains of social risk factors plus health literacy and the health outcomes of Medicare beneficiaries (NASEM, 2016a) (see Figure 1-1)
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34 FIGURE 1-1 Conceptual framework of social risk factors for health care use, outcomes, and cost. NOTE: This conceptual framework illustrates primary hypothesized conceptual relationships.
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Thus, it can be challenging to identify where a given social risk factor lies on this spectrum, particularly as health care providers and plans are increasingly addressing social risk factors for poor health outcomes. To guide this task, it is critical to distinguish between factors that can be modified themselves and factors that are not modifiable themselves, but whose effects on health can be mitigated through provider actions (such as use of tailored interventions)
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so addresses language barriers without changing the underlying language skills of patients and enrollees. The third report expanded the social risk factor framework presented in the first report to include specific indicators of each of the five domains of social risk factors.
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Importantly, such new data collection on social risk factors need not be restricted to Medicare quality measurement and payment applications. CMS could also use these data for other purposes, including research and quality improvement.
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and state agencies oversee and maintain that contain information on social risk factors and that CMS could use. These include data that could be linked to Medicare beneficiary data at the individual level, arealevel data that could be used to describe a Medicare beneficiary's residential environment or serve as a proxy for individual level effects, and data CMS could use to determine how to elicit social risk factor information from Medicare beneficiaries.
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Chapter 3 discusses the methods to account for social risk factors in Medicare payment programs, and also addresses some issues that may arise when implementing those methods. Chapter 4 discusses ways in which ASPE and CMS could move forward with accounting for social risk factors in Medicare VBP programs, should they choose to do so.
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4. here social risk factors change over time and have clinical utility, requiring W data collection through electronic health records or other types of provider reporting may be the best approach.
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2014. Quality measures and socio emographic d risk factors: To adjust or not to adjust.
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2016. HHS reaches goal of tying 30 percent of Medicare payments to quality ahead of schedule.
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2014. Effect of clinical and social risk factors on hospital profiling for stroke readmission: A cohort study.
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2016a. Accounting for social risk factors in Medicare payment: Identifying social risk factors.
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2014. Letter to HHS Secretary Burwell and CMS Administrator Tavenner regarding the Medicare Hospital Readmissions Reduction Program.
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