Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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3 Methods to Account for Social Risk Factors
3 Methods to Account for Social Risk Factors
Pages 77-98
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From page 77... ...
Arguments in support of accounting for social risk factors in VBP are frequently framed in terms of fairness to providers in performance measurement and payment. Although these are direct policy goals of the 10 methods to account for social risk factors the committee identified in its third report, they are but intermediary goals and means of achieving what the committee views as the indirect, but principal, goals of any approach to accounting for social risk factors -- reducing disparities in access, quality, and outcomes and improving quality and efficient care delivery for all patients.
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From page 78... ...
, the committee identified 10 methods in four categories that could be used individually or in combination to account for social risk factors. These categories are Stratified public reporting; A. B. Adjustment of performance measure scores; C. Direct adjustment of payment; and D. Restructuring payment incentive design.
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From page 79... ...
.1 Thus, the chapter also discusses how CMS could mitigate potential unintended consequences. Finally, any approach to accounting for social risk factors will interact with the underlying incentive design to achieve certain policy goals or produce certain adverse consequences.
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From page 80... ...
Thus, if monitoring disparities is an important policy goal, any approach to account for social risk factors must include public reporting stratified by patient characteristics within reporting units. Although stratified reporting can help achieve the goals of reducing disparities for patients with social risk factors, quality improvement and efficient care delivery for all patients, and fair and accurate public reporting, it does not influence provider compensation.
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From page 81... ...
. In other words, such adjustment aims to statistically minimize the effect of factors that may independently influence performance indicators used in VBP, such as social risk factors that make it difficult for providers disproportionately serving socially at-risk populations to improve or achieve performance benchmarks under the status quo (which does not take these factors into account)
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From page 82... ...
Under the status quo, which does not generally account for social risk factors, it is more difficult on average for providers and plans disproportionately serving socially at-risk patients to achieve performance targets owing to the influence of social risk factors. Although incentives to improve care under the status quo may be diminished when performance measure scores are adjusted for within-provider differences, this incentive reflects a disadvantage of these providers under the status quo (the greater average difficulty and greater resources needed to achieve benchmarks)
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From page 83... ...
This could be done by adjusting the payment formula for social risk factors directly (without adjusting performance measures)
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From page 84... ...
Like directly adjusting payments, restructuring payment incentive design does not affect publicly reported measures and therefore does not improve the accuracy of performance scores. Restructuring incentive design does not make disparities visible unless it is combined with public reporting stratified by patient characteristics within reporting units.
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From page 85... ...
.4 The committee takes this opportunity to expand on two potential unintended consequences about which some opponents of accounting for social risk factors have raised particular concerns: reducing incentives to improve care for patients with social risk factors and for patients overall, and obscuring disparities. In particular, the committee suggests how these unintended consequences might be mitigated.
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From page 86... ...
It does not capture the policy goals achieved under the status quo (which generally does not account for social risk factors)
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From page 87... ...
Compared to unadjusted scores, adjustment If payment is based on adjusted allows CMS to remove the influence of certain performance scores, this method could phenomena (e.g., societal-level disparities in fairly compensate providers for their quality) from comparisons of performance direct contribution towards performance between providers who predominantly serve rather than unadjusted scores that populations with social risk factors compared can be influenced by the independent to those who generally do not.
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From page 88... ...
No, if adjustment is Adjustment for within-provider differences Adjustment of adequate to account for the may diminish incentives to improve care performance greater average difficulty for providers disproportionately serving measure of achieving performance socially at-risk populations that reflect their scores benchmarks for socially at- disadvantage (greater average difficulty risk populations compared and greater resources needed to achieve to more advantaged performance targets) under the status quo.
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From page 89... ...
differences. make Note, adjustment for risk disparities factors alone would not Risk is greater for adjustment of visible unless address underpayment that between-provider differences, which may stratified would result if payment conflate differences arising from patient unadjusted for performance were characteristics and provider characteristics scores are still based on unadjusted (including differences in quality)
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From page 90... ...
It does not capture the potential unintended consequences of the status quo (which generally does not account for social risk factors)
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From page 91... ...
For this reason, the committee reiterates that, if CMS's goals for VBP include monitoring and reducing disparities, because only public reporting stratified by patient characteristics within reporting units makes disparities visible by providing quality information for different subgroups, stratified public reporting must be part of any approach to improve on the status quo. Conclusion: The committee supports four goals of accounting for social risk factors in Medicare payment programs: reducing dispari ties in access, quality and outcomes; improving quality and effi cient care delivery for all patients; fair and accurate reporting; and compensating health plans and providers fairly.
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From page 92... ...
Furthermore, improving health equity may require both accounting for social risk factors in payment and quality improvement interventions. HOSPITAL READMISSIONS REDUCTION PROGRAM EXAMPLES The HRRP requires CMS to reduce a share of the base operating payments to acute care hospitals paid under the Inpatient Prospective Payment System that have the highest readmission rates (CMS, 2016b)
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From page 93... ...
As described above, of all the methods of accounting for social risk factors only stratified public reporting can generate these "information" benefits for patients, hospitals, and CMS. If CMS views these mechanisms as important to achieve the policy goals of reducing disparities in access, quality, and outcomes; quality improvement and efficient care delivery for all patients; fair and accurate reporting; and compensating providers fairly, then stratified reporting must be part of any approach to improve on the status quo, where public reporting obscures differences in performance for high- and low-social risk factor groups.
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From page 94... ...
But it would also be true that the incentives to improve care for patients with high social risk factors might be curtailed at lower levels of absolute performance than the incentives to improve care for patients with higher social risk factors -- a hospital with patients with high levels of social risk factors gets to the "no-penalty" zone with poorer absolute readmission rates than a hospital with patients with low levels of social risk factors. With accurate adjustment, hospitals serving low-social risk factor patients might see increased penalties and then be appropriately motivated to work on reducing readmissions for all patients.
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From page 95... ...
The policy goals achieved and potential unintended consequences of directly adjusting payment for the HRRP are similar to adjusting performance measure scores except that adjusting payment alone would leave visible in the single reported readmission rate the reduction in average performance associated with patients with social risk factors. Without stratification this adjusted rate may or may not be better than the status quo (a single rate adjusted for clinical risk factors but not for social risk factors)
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From page 96... ...
2014. Measuring quality and enacting policy: Readmission rates and socio economic factors.
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From page 97... ...
2016a. Accounting for social risk factors in Medicare payment: Criteria, factors, and methods.
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