Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
Currently Skimming:
C2: Criteria for Selecting Social Risk Factors for Application in Medicare Quality Measurement and Payment
C2: Criteria for Selecting Social Risk Factors for Application in Medicare Quality Measurement and Payment
Pages 343-364
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 343... ...
health care system at large shift their focus from providing individual treatments to providing preventive care and improving population health, payment systems have correspondingly reflected a shift from paying for the provision of services (fee-for- service or volume-based payment) to paying for the production of good health care outcomes (value-based payment [VBP]
|
From page 344... ...
Clinical risk factors are patient characteristics that may influence performance indicators used in VBP and may also be unevenly distributed across providers. For this reason, quality measures and payment models currently account for underlying and systematic differences in clinical risk factors known to independently drive variation in performance (NASEM, 2016a)
|
From page 345... ...
GUIDING PRINCIPLES The committee developed selection criteria for social risk factors to support the methods for accounting for social risk factors in Medicare payment, particularly payment tied to performance indicators. Underlying the committee's approach to accounting for social risk factors is a commitment to achieving health equity.
|
From page 346... ...
As described in Appendix C1 and in the committee's first report, critics of accounting for social risk factors in VBP programs are concerned about the potential to institutionalize a poorer standard of care and to reduce incentives to improve care for socially at-risk populations. Proponents are concerned about incentives for providers to avoid socially at-risk populations, further reducing already limited resources among providers disproportionately serving socially at-risk populations, and, consequently, increasing health disparities.
|
From page 347... ...
COMMITTEE PROCESS The criteria put forth by this committee adhere closely to the guidelines for selecting risk factors developed by the National Quality Forum (NQF) in their 2014 report Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors.
|
From page 348... ...
CRITERIA FOR SELECTING SOCIAL RISK FACTORS Conclusion 1: Three overarching considerations encompassing five cri teria could be used to determine whether a social risk factor should be accounted for in performance indicators used in Medicare value-based payment programs. They are as follows: A. The social risk factor is related to the outcome.
|
From page 349... ...
. The main rationale for including social risk factors for which the precise causal mechanism is not well established is the fundamental cause theory (Link and Phelan, 1995)
|
From page 350... ...
Similarly, it would be problematic if all the social risk factors included in a model were selected because of social norms or political considerations rather than an established conceptual relationship. Another practical issue would be to consider whether and how the construct works in a population of interest.
|
From page 351... ...
. For example, one might consider education as a social risk factor for flu immunization in Medicare health plans.
|
From page 352... ...
predict performance indicators used in VBP within reporting units after considering other retained social risk factors. For example, gender might not vary much across health plans (situation a)
|
From page 353... ...
Other considerations include whether the missing data elements regarding social risk factors may be issues that are more subjective and therefore potentially subject to manipulation. Additionally, providers may have the ability to gather information on risk factors, but the desire to collect data providers report should be balanced against the need for objective sources of data.
|
From page 354... ...
to achieve the same health care outcomes. Criterion 3: Risk Factor Is Present at the Start of Care While not a guarantee of avoiding selection of social risk factors that are a consequence of the care provided, identifying factors that are present at the start of care are unlikely to be affected by the care they are about to receive.
|
From page 355... ...
Although themselves unmodifiable, these factors and indeed all efforts at disparity reduction and quality improvement for socially at-risk patients are predicated on the assumption that tailored, appropriate care for those with any particular risk factors is possible. Other factors, like income, wealth, occupation, language, housing, and transportation are potentially modifiable, but doing so likely requires substantial effort and cost.
|
From page 356... ...
Both unmodifiable factors and factors that are potentially modifiable but beyond the purview of the health care system would meet this criterion. Methods of adjusting or otherwise accounting for social risk factors, as described in Appendix C4, can account for unmodifiable risk factors while rewarding providers who provide better, appropriate, tailored care that minimize the impact of social risk factors on certain health care outcomes.
|
From page 357... ...
Gaming the measurement of social risk factors may be less likely if measures are externally collected and reported. Gaming may be more likely if measures used for accounting purposes were based on provider reporting.
|
From page 358... ...
However, the committee does offer guidance on how to apply these criteria. With respect to applying criteria to individual social risk factors, indicators, or measures, the committee proposes: • The rationale for selecting a factor, as well as alternatives consid ered, is transparent.
|
From page 359... ...
o Monitoring is also necessary to assess whether the use of social risk factors in Medicare payment strategies is appropriately incentivizing both improved quality and reduction in health disparities. Yet the criteria themselves are meant to be stable and reapplied to allow for an adaptive system.
|
From page 360... ...
Contribution of unique variation in the outcome (i.e., not redundant or highly correlated with another risk factor) : Prevent overfitting and unstable estimates, or coefficients that appear to be in the wrong direction; reduce data collection burden.
|
From page 361... ...
Prioritize continuous over dichotomous measures of the same constrict where applicable to reduce "edge" gaming. Carefully monitor high-leverage factors (i.e., risk factors that are not prevalent but highly predictive of outcomes)
|
From page 362... ...
2016a. Account ing for social risk factors in Medicare payment: Identifying social risk factors.
|
From page 363... ...
2004. Risk adjustment of Medicare capitation payments using the CMS-HCC model.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.