Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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C4: Methods to Account for Social Risk Factors in Medicare Value-Based Payment
C4: Methods to Account for Social Risk Factors in Medicare Value-Based Payment
Pages 409-444
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From page 409... ...
to account for social risk factors will require weighing these potential harms. Given that the Medicare payment landscape is evolving and the Centers for Medicare & Medicaid Services (CMS)
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. Addi ionally, although not considered entirely VBP models nor do they clas t sify strictly as financial incentives or APMs, Medicare Advantage and Part D have design features that tie quality and cost performance to payment, and thus are relevant for purposes of accounting for social risk factors in payment.
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Current Financial Incentive Programs Penalties for Poor Performance Hospital-Acquired Condition Payment Reduction Program Implemented beginning fiscal year (FY) 2015, the Hospital-Acquired Condition Payment Reduction Program reduces payments to acute care hospitals paid under the Inpatient Prospective Payment System based on their performance on select hospital-acquired condition quality measures, including the Agency for Healthcare Research and Quality Patient Safety Indicator 90 and the Centers for Disease Control and Prevention (CDC)
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Current Alternative Payment Models APM with Downside Risk End-Stage Renal Disease Quality Improvement Program The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 authorized the End Stage Renal Disease (ESRD)
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Other Current Value-Based Payment Models and Mechanisms Medicare Advantage/Part C Bonus Payments Medicare Advantage is the insurance program that covers Part A (inpatient care) and Part B (outpatient care)
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. Skilled Nursing Facility Value-Based Purchasing The Protecting Access to Medicare Act of 2014 authorizes a skilled nursing facility incentive program and also specifies details about quality measures, scoring performance, the performance standards and periods, and public reporting (CMS, n.d.-c)
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Three such payment models that tie payment to quality and efficiency of care delivered to Medicare beneficiaries, and thus for which accounting for social risk factors may be relevant, are described below.
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. As of April 1, 2016, more than 1,500 health care providers were participating in BCPI Phase 2, including 681 skilled nursing facilities, 385 acute care hospitals, 283 physician group practices, 99 home health agencies, 9 inpatient rehabilitation facilities, and 1 long-term care hospital (CMS, 2016a)
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. POTENTIAL HARMS OF THE STATUS QUO COMPARED TO ACCOUNTING FOR SOCIAL RISK FACTORS Although adjustment for social risk factors could have important benefits, any proposal to account for social risk factors in Medicare payment programs will entail its own advantages and disadvantages that need to be
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For example, as described in the previous section, Medicare Advantage plans receive a risk-adjusted annual capitated rate and receive bonuses for achieving quality benchmarks based on performance measures risk adjusted for clinical, behavioral, and some social risk factors under the Five-Star Quality Rating System. However, even after adjustment, plans that have a large number of individuals with social risk factors find it more difficult to achieve the benchmarks because these individuals have lower adherence and greater difficulty managing illnesses, making it difficult for the insurer to obtain star ratings comparable to other plans (Young et al., 2014)
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. Finally, under the status quo, plans and providers that serve mixed populations that include individuals with both low and high levels of social risk factors may find that they have incentives to improve care only for patients with low levels of social risk factors (Casalino et al., 2007)
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Finally, some methods of accounting for social risk factors could obscure differences due to poor quality care, such as failure to tailor care or provide culturally competent care, which may result in uneven relative allocation of rewards relative to effort. Conclusion 4: It is possible to improve on the status quo with regard to the effect of value-based payment on patients with social risk fac tors.
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. Thus, the committee's review of m ethods to account for social risk factors in Medicare VBP programs takes as the point of departure that the goal of Medicare payment and reporting systems are reducing disparities in health care access, affordability, quality, and outcomes; quality improvement and efficient care delivery for all patients; fair and accurate public reporting; and compensating providers for the services they provide.
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The committee reviewed literature on a range of methods to account for social risk factors in public reporting and payment systems for which inclusion of social risk factors may be appropriate, with the aim to be more inclusive. These methods are described briefly in the following text and in more detail in Table C4-1.
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; • risk adjustment of performance data for within- and between provider differences (e.g., to account for all patient-level differences in performance associated with social risk factors) ; and • adding quality measures tailored (and only meaningful)
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1. Stratification by patient Present performance data Social risk factors can be characteristics within for population represented by discrete reporting unitsa subgroups.b strata (e.g., high and low income, Black and white patients)
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Finally, the correlation between the mix of social risk factors and resource constraints may be limited. continued
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2. Risk adjustment of Statistical methods are used Social risk factors can be performance data for to account for (remove)
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disparities. May capture full effects Depending on payment Adjustment will typically of social risk factors on functions, could reduce increase estimated costs for quality measures if caring incentives to improvement.
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Risk adjustment in Alter the payment Social risk factors (social payment formula without threshold or increment of risk factors) can be adjusting measured bonus/penalty based on measured at the patient performancef mix of social risk factors level.
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Finally, the correlation between the mix of social risk factors and resource constraints may be limited. continued
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Pay for improvement Payment formula is based Good measurement of relative to own benchmark in part or wholly based on prior performance of well(to a greater extent or percentage improvement defined unit (how to handle exclusively) , including relative to prior period mergers, etc.)
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Depends on functional form of both the payment formula and the effort required to improve from different baselines. Measuring improvement is noisier than comparing performance to a fixed (achievement)
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are strongly associated with social risk factors. Some performance measures -- like inpatient safety measures -- can be expected to have little relationship to social risk factors.
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. The committee lists this approach here to acknowledge the benefits and risks of such an approach vis à vis accounting for social risk factors in other Medicare payment systems.
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risk adjustment in the payment formula without adjusting measured performance (i.e., apply ing a different payment threshold or increment for rewards or sanctions based on the reporting unit's mix of social risk factors)
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As noted earlier, because achiev TABLE C4-2 Potential Harms of Accounting for Social Risk Factors Compared to the Status Quo Status Quo Accounting for Social Risk Factors Patient dumping/avoidance Reduces this risk relative to the status quo Unfair to providers disproportionately Unfair to providers who provide highserving socially at-risk populations (if factors quality care to all patients if truly poor beyond provider control -- and/or the cost of quality causes poorer performance for improvement is higher for populations with socially at-risk patients social risk factors -- cause poor performance) Will reduce quality and access for socially at- Reduces this risk relative to the status quo risk populations Incentives to improve care might favor Same unless payment is adjusted upward focusing on patients with few social risk for socially at-risk populations factors if they are easier to improve
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Table 2 presents the unadjusted overall score for each provider and nationally, as well as scores stratified by patients' level of social risk. Here, each provider performs better for the lower social risk group than for the disadvantaged group with more social risk factors.
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Finally, it is important to note that the stratified scores by group also convey important information that patients may deserve. In particular, patients in the high risk group might want to know which providers deliver the highest-quality care to patients like themselves.
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Conclusion 7: Strategies to account for social risk factors for measures of cost and efficiency may differ from strategies for quality measure ment, because observed lower resource use may reflect unmet need rather than the absence of waste, and thus lower cost is not always better, while higher quality is always better. MONITORING METHODS TO ACCOUNT FOR SOCIAL RISK FACTORS As described earlier in the chapter, accounting for social risk factors in Medicare value-based purchasing programs is intended to achieve a balance between incentives for reducing disparities in access, quality, and outcomes; quality improvement and efficient care delivery for all patients; fair and accurate public reporting; and compensating providers fairly.
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CONCLUDING REMARKS The committee notes that it is not within its statement of task to recommend whether social risk factors should be accounted for in VBP or how; that decision sits elsewhere. The committee hopes that the conclusions in this report help CMS and the Secretary of HHS make that important decision. In the next report, the committee tackles the question of how to gather the data that could be used to account for social risk factors in Medicare VBP.
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2015a. End-Stage Renal Disease Quality Incentive Program frequently asked ques tions.
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2015. Accounting for socioeconomic status in Medicare payment programs: ASPE's work under the IMPACT Act.
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2016a. Account ing for social risk factors in Medicare payment: Identifying social risk factors.
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2016. Medicare's vision for advanced primary care: New directions for care delivery and payment.
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