ACCOUNTING FOR
Social Risk Factors
IN
Medicare Payment
Identifying Social Risk Factors
Committee on Accounting for Socioeconomic Status in Medicare Payment Programs
Board on Population Health and Public Health Practice
Board on Health Care Services
Institute of Medicine
THE NATIONAL ACADEMIES PRESS
Washington, DC
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by Contract No. HHSP233201400020B from the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-38124-6
International Standard Book Number-10: 0-309-38124-X
DOI: 10.17226/21858
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Copyright 2016 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016. Accounting for social risk factors in Medicare payment: Identifying social risk factors. Washington, DC: The National Academies Press.
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COMMITTEE ON ACCOUNTING FOR SOCIOECONOMIC STATUS IN MEDICARE
PAYMENT PROGRAMS
DONALD M. STEINWACHS (Chair), Professor, Johns Hopkins Bloomberg School of Public Health
JOHN Z. AYANIAN, Alice Hamilton Professor of Medicine, Director, Institute for Healthcare Policy and Innovation, University of Michigan
CHARLES BAUMGART, Senior Medical Director, xG Health Solutions
MELINDA BUNTIN, Chair, Department of Health Policy, Vanderbilt University School of Medicine
ANA V. DIEZ ROUX, Dean and Distinguished Professor of Epidemiology, Drexel University Dornsife School of Public Health
MARC N. ELLIOTT, Senior Principal Researcher, RAND Corporation
JOSÉ J. ESCARCE, Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles
ROBERT FERRER, Dr. John M. Smith, Jr. Professor, Department of Family & Community Medicine, University of Texas Health Science Center at San Antonio
DARRELL J. GASKIN, Associate Professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
MARK D. HAYWARD, Professor of Sociology, Centennial Commission Professor in the Liberal Arts, Faculty Research Associate, Population Research Center, University of Texas at Austin
JAMES S. JACKSON, Daniel Katz Distinguished University Professor of Psychology, Research Professor, Institute for Social Research, University of Michigan
DANIEL POLSKY, Executive Director, Leonard Davis Institute of Health Economics, University of Pennsylvania
MEREDITH ROSENTHAL, Professor of Health Economics and Policy, Harvard T.H. Chan School of Public Health
ANTHONY SHIH, Executive Vice President, The New York Academy of Medicine
Study Staff
KATHLEEN STRATTON, Study Director
LESLIE Y. KWAN, Associate Program Officer
EMILY VOLLBRECHT, Senior Program Assistant
REBECCA MORGAN, Senior Research Librarian
DORIS ROMERO, Financial Associate
HOPE HARE, Administrative Assistant
ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice
SHARYL NASS, Board Director, Board on Health Care Services
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Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
JACK EBELER, Independent Consultant
LEE FLEISHER, University of Pennsylvania School of Medicine
DEBORAH A. FREUND, Claremont Graduate University and RAND Corporation
PAMELA HERD, University of Wisconsin–Madison
LISA I. IEZZONI, Harvard Medical School and Massachusetts General Hospital
DAVID R. NERENZ, Henry Ford Health System
THOMAS RICE, University of California, Los Angeles, Fielding School of Public Health
JOSHUA M. SHARFSTEIN, Johns Hopkins Bloomberg School of Public Health
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by GEORGES C. BENJAMIN, American Public Health Association, and CHARLES E. PHELPS, University of Rochester. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Contents
Current Status of Value-Based Payment in Medicare
Committee Process and Overview of This Report
Definitions and Findings from the Literature Search
Overview of the Medicare Program
Current Status of Value-Based Payment in Medicare
Committee Process and Overview of This Report
Definitions and Literature Search
A OVERVIEW OF MEDICARE VALUE-BASED PAYMENT PROGRAMS
Medicare Value-Based Payment Programs for Hospital Inpatient Care
Medicare Value-Based Payment Programs for Ambulatory Care
Medicare Value-Based Payment Programs for Health Plans
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ACA | Patient Protection and Affordable Care Act of 2010 |
ACO | accountable care organization |
ADL | activity of daily living |
AHRQ | Agency for Healthcare Research and Quality |
AMI | acute myocardial infarction |
APM | alternative payment model |
BY | benchmark year |
CAHPS | Consumer Assessment of Healthcare Providers and Systems |
CAUTI | Catheter-Associated Urinary Tract Infection |
CDC | Centers for Disease Control and Prevention |
CHIP | Children’s Health Insurance Program |
CLABSI | Central-Line Associated Bloodstream Infection |
CMS | Centers for Medicare & Medicaid Services |
COPD | chronic obstructive pulmonary disease |
CY | calendar year |
ED | emergency department |
ESRD | end-stage renal disease |
FY | fiscal year |
GAO | Government Accountability Office |
HAC | hospital-acquired condition |
HCAHPS | Hospital Consumer Assessment of Healthcare Providers and Suppliers |
HCC | hierarchical condition categories |
HF | heart failure |
HHS | Department of Health and Human Services |
HRRP | Hospital Readmission Reductions Program |
IADL | instrumental activity of daily living |
IMPACT Act | Improving Medicare Post-Acute Care Transformation Act of 2014 |
IOM | Institute of Medicine |
IPPS | Inpatient Prospective Payment System |
LEP | limited English proficiency |
MA | Medicare Advantage/Medicare Part C |
MIPS | Merit-Based Incentive Payment System |
MedPAC | Medicare Payment Advisory Commission |
MIPPA | Medicare Improvements for Patients and Providers Act |
MLR | minimum loss rate |
MSPB | Medicare spending per beneficiary |
MSR | minimum savings rate |
MSSP | Medicare Shared Savings Program |
NHSN | National Healthcare Safety Network |
NQF | National Quality Forum |
PN | pneumonia |
PQRS | Physician Quality Reporting System |
PSA | prostate-specific antigen |
PSI | patient safety indicator |
SEP | socioeconomic position |
SES | socioeconomic status |
SNF | Skilled Nursing Facility |
SSI | Surgical Site Infection |
STEMI | ST-segment elevation myocardial infarction |
VA | Department of Veterans Affairs |
VBP | value-based payment |