Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
Currently Skimming:
C3: Applying Selection Criteria to Social Risk Factors and Health Literacy
C3: Applying Selection Criteria to Social Risk Factors and Health Literacy
Pages 365-408
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 365... ...
, the committee expects the effect of social risk factors to be similar for all Medicare subpopulations. As described in its first report, the committee considers variations in the effect of social risk factors among beneficiaries under age 65 with disabilities, beneficiaries age 65 and older, and beneficiaries with ESRD to fall within a continuous spectrum of effects.
|
From page 366... ...
, and also identifies the rationale and limitations of each factor and indicator relative to those criteria. To review, the committee identified three broad categories of criteria for selecting social risk factors that could be accounted for in Medicare VBP programs: A. The social risk factor is related to the outcome; B. The social risk factor precedes care delivery and is not a conse quence of the quality of care; and C. The social risk factor is not something the provider can manipulate.
|
From page 367... ...
. Thus, literature supports a conceptual relationship between income and health-relevant measures of interest to Medicare quality and payment programs.
|
From page 369... ...
For the indicators listed in bullets under each social risk factor, bold lettering denotes measurable indicators that could be accounted for in Medicare VBP programs in the short term; italicized lettering denotes measurable indicators that capture the basic underlying constructs and currently present practical challenges, but are worth attention for potential inclusion in accounting methods in Medicare VBP programs in the longer term; and plain lettering denotes indicators that have considerable limitations. aAs described in the conceptual framework outlining primary hypothesized conceptual relationships between social risk factors and outcomes used in value-based payment presented in the committee's first report (NASEM, 2016a)
|
From page 370... ...
. Literature supports a conceptual relationship between wealth and health care outcomes of interest, but a lack of available measures and thus evidence of an empirical association present limitations for using wealth as an indicator of SEP.
|
From page 371... ...
Relatedly, dual eligibility may capture clinical characteristics covering those who are under age 65 and eligible for Medicaid coverage based on disability. As noted in the introduction, the committee expects social risk factors to operate similarly among all Medicare beneficiaries including disabled persons.
|
From page 372... ...
Because dual eligibility captures elements of income, wealth, and health status, dual eligibility can be considered a broader measure of healthrelated resource availability that captures medical need. Dual eligibility is empirically associated with health and health care outcomes including health care utilization, clinical processes of care, and patient experience (NASEM, 2016a)
|
From page 373... ...
. Thus, literature supports a conceptual relationship between education and performance indicators used in VBP.
|
From page 374... ...
In its first report (see Appendix A) , the committee identified literature indicating that race and ethnicity may influence health care utilization, clinical processes of care, health care costs, health outcomes, patient safety, and patient experiences of care (NASEM, 2016a)
|
From page 375... ...
In sum, race and ethnicity are related to health care outcomes, precede care delivery and are not a consequence of the quality of care, are not things a provider can manipulate, and meet practical considerations. At the same time, the committee acknowledges that causal pathways by which race and ethnicity influence health include mechanisms that can be related to quality of care.
|
From page 376... ...
Literature supports a conceptual relationship between acculturation and health care outcomes of interest, but existing measures pose challenges to feasibility. Consequently, there is a lack of empirical evidence about the relationship between acculturation and performance indicators used in VBP.
|
From page 377... ...
. Measures of gender identity are likely to be resistant to gaming or manipulation, but because there is a very low prevalence of gender minorities, gender identity is unlikely to have a significant effect in adjustment models and other methods of accounting for social risk factors.
|
From page 378... ...
Taken together, like gender identity, emerging literature supports a relationship between sexual orientation and health care outcomes of interest, but poor existing measures have limited available evidence. Summary Normative gender categories (men and women)
|
From page 379... ...
In its first report (see Appendix A) , the committee identified literature indicating that marital status may influence health care utilization, clinical processes of care, health care outcomes, patient experiences of care, and health care costs (NASEM, 2016a)
|
From page 380... ...
. Nevertheless, the committee identified literature indicating that living alone may influence health care utilization, clinical processes of care, and health outcomes in its first report (NASEM, 2016a)
|
From page 381... ...
. Hence, literature supports a B conceptual relationship between social support and performance indicators used in VBP.
|
From page 382... ...
Some evidence suggests that the relationship between marital/partnership status and health is changing along with demographic shifts, which point to a need to reassess the empirical associations and revisit assumptions about the conceptual relationship over time. Emotional social support and instrumental social support are likely to influence health care outcomes.
|
From page 383... ...
. In its first report, the committee identified literature indicating that compositional characteristics may influence health care utilization, clinical processes of care, health care outcomes, and patient safety (NASEM, 2016a)
|
From page 384... ...
. In total, despite some measurement issues, compositional characteristics of residential and community context are related to performance indicators used in VBP, precede care delivery and are not a consequence of the quality of care, are not things a provider can manipulate, and generally meet practical considerations.
|
From page 385... ...
In its first report (see Appendix A) , the committee identified literature indicating that urbanicity may influence health care utilization, clinical processes of care, health care costs, and patient experiences of care, particularly at the far ends of the spectrum (NASEM, 2016a,b)
|
From page 386... ...
, the committee also identified case studies in which housing conditions -- stairs and loose wires -- were considered risk factors for poor health care outcomes (e.g., falls)
|
From page 387... ...
Act and therefore of interest to Congress. Additionally, social risk factors like education and 1 The committee sees no conflict between this report and the 2013 IOM report Variation in Health Care Spending: Target Decision Making, Not Geography, which recommended against using area-level payment adjustments to account for regional practice patterns.
|
From page 388... ...
. In its first report, the committee also identified literature indicating that health literacy may influence health care utilization, clinical processes of care, health care cost, and patient experiences of care (NASEM, 2016a)
|
From page 389... ...
After applying the selection criteria to indicators of the five social risk factors and health literacy, the committee made the following conclusions: Conclusion 2: There are measurable social risk factors that could be accounted for in Medicare value-based payment programs in the short term. Indicators include • Income, education, and dual-eligibility; • Race, ethnicity, language, and nativity; • Marital/partnership status and living alone; and • Neighborhood deprivation, urbanicity, and housing.
|
From page 390... ...
Resistant to gaming/manipulation (5) Insurance Specifically, Medicaid Has a conceptual relationship with (as a proxy status/dual eligibility performance indicators used in VBP (1)
|
From page 391... ...
labor force (including all who are eligible Potentially susceptible to (rapid) changes based on disability)
|
From page 392... ...
Race, Ethnicity, and Cultural Context Race and Social categories that are Has a conceptual relationship with ethnicity dimensions of society's performance indicators used in VBP (1) stratification system Has an empirical relationship with by which resources, performance indicators used in VBP (2)
|
From page 393... ...
APPENDIX C 393 Potential Limitations/Challenges Other Considerations Lack of evidence of associations with Practical considerations will depend on the outcomes (2) specific measure Refinement of standardized race and Some existing standards include White House ethnicity measures is still needed; there Office of Management and Budget standards can be substantial heterogeneity within and IOM recommendations (IOM, 2009)
|
From page 394... ...
Documentation status as a measure of immigration history is likely to be sensitive to collect. Literature supports a conceptual relationship between acculturation and health care outcomes of interest, but existing measures have limitations and empirical evidence is lacking.
|
From page 395... ...
significant effect in adjustment models: Differential health outcomes may CMS is piloting measures for sexual arise from provider–patient encounter orientation that could be revisited for (miscommunication, lack of cultural potential inclusion when there is more data competence, bias)
|
From page 396... ...
research Emotional Key function of social Has a conceptual relationship with and relationships, includes performance indicators used in VBP (1) instrumental emotional elements Has an empirical relationship with social support (e.g., through caring performance indicators used in VBP (2)
|
From page 397... ...
prevalence of older adults living alone; may be important to measure with regional interactions Measuring social support can be challenging (2) Potentially susceptible to rapid changes (3)
|
From page 398... ...
English language– proficient residents, either individually or in composite (e.g., in a summary neighborhood deprivation measure) Environmental Dimensions of residential Has a conceptual relationship with measures environments including performance indicators used in VBP (1)
|
From page 399... ...
Potentially susceptible to (rapid) changes as a consequence of a health event (3)
|
From page 400... ...
basic health information and services needed to make appropriate health decisions; numeracy describes the ability to understand information presented in mathematical terms and to use mathematical knowledge and skills in a variety of applications across a variety of settings SUMMARY Health literacy is the result of social risk factors and the effects of low literacy can be mitigated via actions that are squarely within the purview of the health care system. Thus, risk adjustment is likely to reduce incentives to tailor care to or improve patients' health literacy.
|
From page 401... ...
Malleable in individuals and can be improved as a consequence of the quality of care provided (3) Providers can act upon to ameliorate effects; thus, potentially a characteristic of care (4)
|
From page 402... ...
Finally, as described in Appendix C2, the committee expects the relationships between social risk factors and health and health care outcomes to change over time. Thus, it will be important to continuously evaluate the individual risk factors, indicators, and measures as well as the overall set of measures over time.
|
From page 403... ...
2000. Social integration, social networks, social support, and health.
|
From page 404... ...
2015. Sexual minorities in England have poorer health and worse health care experiences: A national survey.
|
From page 405... ...
2004. Health literacy: A prescription to end confusion.
|
From page 406... ...
2016a. Account ing for social risk factors in Medicare payment: Identifying social risk factors.
|
From page 407... ...
2006. The relation of social isolation, loneliness, and social support to disease outcomes among the elderly.
|
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.