This appendix lists the committee’s conclusions and recommendations from its previous reports. The committee’s first report, Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors (NASEM, 2016a), had no conclusions or recommendations, only findings.
REPORT 2: SYSTEMS PRACTICES FOR THE CARE OF SOCIALLY AT-RISK POPULATIONS1
The committee concluded that six community-informed and patient-centered systems practices show promise for improving care for socially at-risk populations:
- Commitment to health equity: Value and promote health equity and hold yourself accountable.
- Data and measurement: Understand your population’s health, risk factors, and patterns of care.
- Comprehensive needs assessment: Identify, anticipate, and respond to clinical and social needs.
- Collaborative partnerships: Collaborate within and across provider teams and service sectors to deliver care.
- Care continuity: Plan care and care transitions to prepare for patients’ changing clinical and social needs.
- Engaging patients in their care: Design individualized care to promote the health of individuals in the community setting
REPORT 3: ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT: CRITERIA, FACTORS, AND METHODS2
Conclusion 1: Three overarching considerations encompassing five criteria 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:
The social risk factor is related to the outcome.
- The social risk factor has a conceptual relationship with the outcome of interest.
- The social risk factor has an empirical association with the outcome of interest.
The social risk factor precedes care delivery and is not a consequence of the quality of care.
- The social risk factor is present at the start of care.
- The social risk factor is not modifiable through provider actions.
The social risk factor is not something the provider can manipulate.
- The social risk factor is resistant to manipulation or gaming.
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.
Conclusion 3: There are some indicators of social risk factors that capture the basic underlying constructs and currently present practical challenges, but they are worth attention for potential inclusion in accounting methods in Medicare value-based payment programs in the longer term. These include
- Gender identity and sexual orientation,
- Emotional and instrumental social support, and
- Environmental measures of residential and community context.
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 factors. However, it is also important to minimize potential harms to these patients and to monitor the effect of any specific approach to accounting for social risk factors to ensure the absence of any unanticipated adverse effects on health disparities.
Conclusion 5: Characteristics of a public reporting and payment system that could accomplish the goals of 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 include
- Transparency and accountability for overall performance and performance with respect to socially at-risk members of the population;
- Accurate performance measurement—with high reliability and without bias (systematic error) related to differences in populations served;
- Incentives for improvement overall and for socially at-risk groups, both within reporting units (i.e., the provider setting that is being evaluated—hospitals, health plans, etc.) and between reporting units.
Conclusion 6: To achieve goals of 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, a combination of reporting and accounting in both measures and payment are needed.
Conclusion 7: Strategies to account for social risk factors for measures of cost and efficiency may differ from strategies for quality measurement, 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.
Conclusion 8: Any specific approach to accounting for social risk factors in Medicare quality and payment programs requires continuous
monitoring with respect to the goals of 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.
ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT:
Recommendation 1: The committee recommends the Centers for Medicare & Medicaid Services (CMS) use five guiding principles when choosing data sources for specific indicators of social risk to be used in Medicare performance measurement and payment. These guiding principles are as follows:
- CMS should first use data it already has.
- CMS should second look for opportunities to use existing data collected by other government agencies (including elsewhere in the Department of Health and Human Services).
- To the extent that a social risk factor is relatively stable, CMS should examine the feasibility of collecting additional data at the time of enrollment in Medicare.
- Where social risk factors change over time and have clinical utility, requiring data collection through electronic health records or other types of provider reporting may be the best approach.
- For social risk factors that reflect a person’s context or environment, existing data sources that can be used to develop area-level measures should be considered.
Recommendation 2: The committee recommends that the Centers for Medicare & Medicaid Services use existing data on dual eligibility, nativity, and urbanicity/rurality in Medicare performance measurement and payment.
Recommendation 3: Data for individual measures of race and ethnicity, language, and marital/partnership status and for area-level measures of income, education, and neighborhood deprivation are currently available and the committee recommends that the Centers for Medicare & Medicaid Services (CMS) use them for performance measurement and payment applications in the short term. However, owing to limitations
in these data, CMS should research ways to improve accuracy and collection of individual-level measures of race and ethnicity, language, marital/partnership status, income, and education, as well as an area-level measure of neighborhood deprivation for use in the future.
Recommendation 4: Individual measures of wealth, living alone, and social support exist, but they are sufficiently limited to preclude use by the Centers for Medicare & Medicaid Services (CMS) in Medicare performance measurement and payment at this time. Therefore, the committee recommends that CMS research ways to accurately collect data on these indicators.
Recommendation 5: Area-level measures exist for housing, but they have limitations for use by the Centers for Medicare & Medicaid Services (CMS) in Medicare performance measurement and payment at this time. The committee recommends that CMS research ways to accurately collect housing data, whether at an individual level or an area level.
Recommendation 6: The committee recommends that research be conducted on the effect of acculturation, sexual orientation and gender identity, and environmental measures of residential and community context on health care outcomes of Medicare beneficiaries and on methods to accurately collect relevant data in the Medicare population.
Recommendation 7: The committee recommends that the Centers for Medicare & Medicaid Services collect information about relevant, relatively stable social risk factors, such as race and ethnicity, language, and at the time of enrollment.
Conclusion 1: If there are substantial barriers to collecting social risk factor data (such as high cost) and/or if early pilot testing or modeling in a multivariable model suggests only marginal gains from including any given indicator in any method of accounting for social risk factors in Medicare performance measurement and payment, inclusion of that social risk factor may not be warranted.
Conclusion 2: Different data collection strategies for the same social risk factor indicator may be warranted depending on the purpose or methods used to account for social risk factors in Medicare performance measurement and payment. Additionally, the advantages and disadvantages of any specific source should be considered in reference to the intended use.
Conclusion 3: Any specific social risk factor indicator may require a multi-modal approach to data collection.
Conclusion 4: Regardless of the source, research on how to accurately and reliably collect social risk factor data across different modes and in different settings will be needed.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2016a. Accounting for social risk factors in Medicare payment: Identifying social risk factors. Washington, DC: The National Academies Press.
NASEM. 2016b. Accounting for social risk factors in Medicare payment: Criteria, factors, and methods. Washington, DC: The National Academies Press.
NASEM. 2016c. Accounting for social risk factors in Medicare payment: Data. Washington, DC: The National Academies Press.
NASEM. 2016d. Systems practices for the care of socially at-risk populations. Washington, DC: The National Academies Press.