Index
A
Accountable care organizations (ACOs)
accounting for social risk factors, 514-515
Medicare Shared Savings Program, 110, 128-129, 135-136, 209-210, 326, 412-413, 415, 416
Next Generation, 327, 415, 416-417
provider risk, 24-25, 125, 335
reducing readmissions, 289, 291
safety-net, 278
unintended consequences, 219, 229
Acculturation
community context, 383
data sources and collection, 377, 395, 512, 526-527, 539
duration in United States and, 57, 58, 375-376, 512
and health and health care, 57, 176, 319, 376, 383, 467-468, 511-512
language proxy for, 57, 58, 376, 392, 512, 526, 527
measures, 57, 58, 319, 375-376, 394, 512
nativity proxy for, 57, 175, 376, 394
race and ethnicity and, 58, 376, 394-395, 512
recommendation, 467, 511-512, 539
value/stability as indicator, 58, 319, 326, 376, 377, 402, 457, 479, 495, 537
Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Indicator, 116, 120, 128, 135, 150, 208, 209
Alliance of Community Health Plans, 222, 233, 243, 303
Ambulatory care
End-Stage Renal Disease Quality Improvement Program, 110, 130-131, 136-137, 211-212, 326, 412-413
Medicare Shared Savings Program, 110, 128-129, 135-136, 209-210, 326, 412-413
Physician Value-Based Modifier, 136, 210-211, 326, 412, 415
race and ethnicity and, 172
value-based payment (VBP) programs, 135-137, 209-212
American Community Survey
area-level data, 10, 38, 49, 52, 57, 63, 65, 460, 465, 467
description, 489
education data, 52, 465, 506, 520, 521
living alone data, 524
neighborhood deprivation indicators, 63, 460, 522
sample size limitations, 489, 507
urbanicity/rurality data, 516, 517
B
Behavioral Risk Factor Surveillance System (BRFSS), 68, 377, 513
Bundled payments, 24-25, 109, 137, 327, 416, 434
Bundled Payments for Care Improvement (BPCI) Initiative, 110 n.1, 127 n.1, 335, 415, 416
C
Centers for Disease Control and Prevention, 128, 132, 135, 137, 208, 209, 411, 412
Centers for Medicare & Medicaid Services (see also Medicare; Value-based payment in Medicare)
Accountable Health Communities model, 26, 231
Equity Plan for Improving Quality in Medicare, 59, 468, 512-513, 528
Hierarchical Condition Category (HCC) clinical risk adjustment model, 101, 132-133, 136, 213, 348, 445-449
Home Health Outcome Assessment Information Set, 61, 510
Innovation Center, 26
Office of Minority Health, 57, 503
Strategic Language Access Plan, 56, 502
Clinical processes of care
community composition and, 120
dual eligibility and, 372
education and, 165
gender identity and, 119, 178, 220
health literacy and, 121, 160, 191, 268, 281-282, 388
income and, 118, 162, 164, 184-185, 367
language proficiency and, 119, 173-174, 175
living alone and, 120, 180, 380
marital/partnership status and, 120, 179, 379
occupation and, 165-166
quality measures, 116, 128, 135, 208-209, 241
race and ethnicity and, 119, 169-170, 173, 191, 374
sexual orientation and, 119, 177-178, 220
social support and, 120, 181, 381
urbanicity/rurality and, 121, 189, 385
Clinical risk factor adjustments, 1, 3-4, 12, 28-29, 69, 70-71, 95, 102, 191, 337, 344-345, 437
Community context, defined, 260 (see also Cultural context; Residential and community context)
Community health centers, 221, 233, 237, 239, 240, 276, 278, 306, 335-336, 418, 486
federally qualified health centers, 239, 278, 279, 284
Community-informed care, 4, 18, 24, 31, 103, 223, 224, 244, 245, 260-261, 262, 266, 275, 286, 287, 288-289, 303, 316, 338, 477, 535
Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, 93, 128, 165, 172, 174, 348, 353, 445, 448, 482-483, 519, 520
Costs of care (see also Resource use, defined)
educational attainment and, 164
health literacy and, 121, 160, 190, 191, 388
language proficiency and, 174
marital/partnership status and, 120, 379
Medicare quality measure examples, 116, 150
nativity and, 176
race and ethnicity and, 119, 121, 173, 191-192, 374
urbanicity/rurality and, 121, 189, 385
Critical access hospitals, 27, 220-221, 233, 237, 239, 335-336, 418, 486
Cultural competency training, 264-265
Cultural context (see also Acculturation; Language barriers/proficiency; Nativity)
definition and constructs, 6
D
Data sources and collection issues (see also Electronic health record data)
acculturation, 377, 395, 512, 526-527, 539
accuracy considerations, 10, 37, 38, 39, 40, 48, 101, 353, 457-458, 461, 462, 496, 498, 526
alternative government sources, 7-8, 38, 459-460, 488-490 (see also American Community Survey; Social Security Administration)
approach to collecting data, 149-151, 469, 471, 514-530
area-level measures as proxies for individual-level constructs, 10, 38, 49, 52, 57, 62-63, 100, 120, 181-184, 383-384, 459, 460, 465, 488, 489, 503, 505, 506, 507, 520, 521
burden and cost of collection, 7, 10, 37, 38, 39, 54, 57, 62, 100, 101, 320, 352, 353, 360, 382, 386, 388, 401, 450, 457-458, 459, 460, 462, 463, 482, 484, 487, 496, 498, 500, 504, 509, 516, 517, 520, 522, 526
categories, 37
clinical usefulness, 10, 39, 40, 52, 56, 57, 60, 61, 62, 459, 460, 461, 462, 463, 464, 466, 467, 485, 496, 497, 498, 500, 502-503, 506, 510, 511, 516, 520, 522, 524, 526, 538
Centers for Medicare & Medicaid Services (CMS) administrative records, 7, 37, 55, 64, 458, 459, 463, 464, 482-484, 501, 502
Centers for Medicare & Medicaid Services (CMS) surveys, 7, 9, 37, 55, 56, 61, 93, 102, 128, 165, 172, 174, 186, 348, 353, 386, 445, 448, 458, 482-483, 509-510, 519, 520,
collection considerations, 37-39, 100-101, 460-469
committee process, 149-151, 457, 477, 479
education, 10, 37, 49, 52, 100, 112, 458, 463-464, 468, 469, 483, 484, 505-506, 520-521
gender identity, 10, 58, 59, 68-69, 324, 377, 467, 468, 485, 488, 511-513, 528-529, 539
guiding principles for choosing, 39, 40, 52, 345-347, 461-462, 498, 500, 538
housing, 65, 386, 398, 458, 460, 467, 484, 489, 496, 508, 510-511, 526, 539
imputed data, 56, 57, 464, 469, 502, 503, 515, 518, 519
income, 48-49, 162-163, 367, 460, 465, 469, 481, 487, 488, 501, 504-505, 507, 514, 520-521, 523
language barriers, 7, 10, 38, 56-57, 100, 271, 319, 375, 458, 459, 463-464, 468, 469, 481, 483, 484, 485, 502-503, 514, 517, 518-519, 526, 527, 538-539
living alone, 61, 466, 508, 509-510, 524-525, 539
marital/partnership status, 60, 463-465, 501, 503-504, 520-521, 538, 539
national surveys (other than American Community Survey [ACS]), 489-490
nativity, 57, 58, 463, 469, 500, 514, 516, 517
neighborhood deprivation, 63, 387, 463-464, 465, 501, 506-507, 508, 522-523
neighborhood environments, 10, 38, 63, 513-514
occupation, 54, 165-166, 185, 372-373
prior conclusions, 538-540
privacy and security concerns, 38, 53, 320, 353, 360, 459, 460, 487, 488, 508
providers and insurance plans, 7, 37-38, 458-459, 484-487
race and ethnicity, 7, 10, 37, 38, 39, 55-56, 169, 266, 271, 374, 375, 457, 458, 463-464, 468, 469, 481-482, 483, 484, 485, 501, 502, 514, 515, 518-519, 538-539
recommendations, 37, 49, 461-469, 538-540
risk tiering tool, 273
sample size considerations, 446, 447, 448, 484, 488, 489, 490, 507, 528
self-identification and self-reporting, 38, 48, 53, 55, 56, 58, 129, 166, 167, 169, 175, 238, 367, 370, 374, 377, 380, 457, 464, 466, 469, 481, 502, 504, 508, 512, 515, 519
sexual orientation, 10, 59, 68-69, 324, 378, 467, 468, 485, 488, 511-513, 528-529, 539
Social Security Administration, 10, 38, 49, 57, 58, 459-460, 463, 465, 469, 488-490, 500, 504, 505, 514, 516, 517, 519, 520, 521
social support, 62, 466, 467, 508, 510, 524-525, 539
standardization issues, 10, 38, 49-50, 52, 55-56, 57, 59, 60, 61, 62, 100, 251, 271, 305, 374, 393, 457-462, 464-468, 481-486, 488, 489, 497, 499, 502, 503, 505, 506, 510, 513, 518-522, 524, 526, 528, 529
statement of task, 456-457, 476-477, 478
urbanicity/rurality, 64, 100, 463, 499, 501, 506, 516-517, 523, 538
wealth, 508-509
Disability
built environment and, 187
capture in current risk adjustment systems, 12, 70, 114, 131, 136, 147, 149, 213
dual eligibility and, 52, 371, 372
and health and health care, 12, 69, 71
and health literacy, 190
income data, 504
interventions by providers, 283
qualification as Medicare beneficiary, 70, 109, 125-126, 127, 147, 149, 350, 372, 391
value/stability as indicator, 71, 318
wealth and, 162
Dual eligibility
and clinical processes of care, 372
data sources and collection, 52, 463, 499-500, 516-517
and health and health care, 52, 371, 372
as income proxy, 52, 68, 100, 117, 161, 371, 372, 390, 392, 500
and patient experience, 372
and utilization of health care, 163, 164, 273
value/stability as indicator, 48, 68, 100, 117, 319, 326, 371-372, 373-374, 389, 390, 457, 479, 495, 536
as wealth proxy, 52, 53-54, 68, 371, 372, 500, 509, 522
E
Education
and clinical processes of care, 165
and costs of care, 164
data sources and collection, 10, 37, 49, 52, 100, 112, 458, 463-464, 468, 469, 483, 484, 505-506, 520-521
and health and health care, 49, 118, 161, 164, 165, 183, 284, 373, 383, 391, 392, 465, 505-506
and health literacy, 12, 49, 69, 325, 387-388
and income, 48, 49, 118, 162, 164, 367, 373, 465, 504, 506
interventions by providers, 26, 257, 259, 261, 264, 267, 277-278, 279, 280, 283, 284, 285, 304, 307, 308
measures of status, 49, 52, 100, 164-165, 183, 366, 373, 477, 506, 520-521
and occupation/employment, 49, 164, 373, 465, 506
and patient experience, 118, 129, 131, 133, 165
and quality and resource use, 145
and racial/ethnic disparities, 284
recommendations, 10, 37, 52, 463, 468, 501, 538-539
residential and community context, 63, 100, 140, 182, 183, 185, 188, 383, 513
and utilization of health care, 118, 161, 164-165, 183, 185
value/stability as indicator, 37, 52, 68, 100, 261, 319, 326, 351, 352, 354, 356, 373, 389, 390, 392, 425, 465, 479, 490, 495, 501, 514, 536, 538-539
Electronic health record (EHR) data
adoption and interoperability extent, 459, 469, 484-485, 486-487, 515
barriers to collection, 486-487
burdens of collecting, 459, 463, 487
clinical utility, 497
comprehensive needs assessment and, 274
educational attainment, 49-50, 52, 458, 465, 484, 506
housing, 65, 458, 467, 484, 511, 527
language, 7, 38, 458, 484, 485, 518-519
living alone, 61, 466, 510, 525
meaningful use, 52, 56 n.6, 57, 377, 378, 415, 459, 485, 506
partnership status, 60, 464, 503, 521
privacy and security issues, 459
race and ethnicity, 7, 38, 55, 458, 464, 484, 485, 502, 518
research needs, 54, 466, 509, 521
residential and community context, 64, 65, 458, 501, 511, 516, 522
sexual orientation and gender identity, 58, 68, 485, 513, 529
social and behavioral risk factors, 461, 485, 497
standardization of collection measures, 466-467, 485, 486-487, 506, 510, 519, 521
urbanicity/rurality, 64, 463, 516
Employment (see also Occupation)
and clinical processes of care, 165-166
and community/neighborhood-level socioeconomic position (SEP), 63, 140, 182, 185, 188, 383, 507
data sources and collection, 54, 165, 166, 372-373, 391, 465, 507
education and, 49, 373, 465, 506
and health and health care outcomes, 161, 165, 372, 373, 465, 506
and patient experience, 166
and quality of care, 372-373
and utilization of health services, 165-166, 185
value/stability as indicator, 165, 365-366, 372-373, 390-391
of working aged, 212 n.1
End-stage renal disease (ESRD), 109, 114, 115, 125-126, 147, 149, 151, 318, 365
End-Stage Renal Disease Quality Incentive Program, 110, 130-131, 136-137, 211-212, 326, 412-413
F
Fee-for-service payment systems, 1, 3, 24, 25, 109, 125, 126, 136, 137, 212, 219, 315, 326, 335, 343, 410, 416, 475 n.1
Food sufficiency/insecurity, 3, 24, 163, 166, 270, 290, 357, 392
G
Gender (normative), 121, 147, 159, 177, 191, 220, 319, 335, 352, 355, 365, 370, 377, 378, 379, 394-395, 396, 448, 457, 477, 481, 495
defined, 119
Gender identity (nonconforming)
and clinical processes of care, 119, 178, 220
data sources and collection, 10, 58, 59, 68-69, 324, 377, 467, 468, 485, 488, 511-513, 528-529, 539
definition and constructs, 6, 58, 319, 324, 377, 394, 468, 512
and health and health care, 58, 113, 119, 177-178, 377-379, 468
measures, 377-378, 395, 468, 512-513
and patient experience, 119, 178
performance of providers, 220, 229, 230, 237
recommendations, 467, 511-512, 539
value/stability as indicator, 10, 59, 68, 324, 326, 379, 394-395, 396, 402, 457, 479, 496, 513, 537
H
Health and health care
acculturation and, 57, 176, 319, 376, 383, 467-468, 511-512
community composition and, 120
community context and, 121
dual eligibility and, 52, 371, 372
education and, 49, 118, 161, 164, 165, 183, 284, 373, 383, 391, 392, 465, 505-506
gender identity and, 58, 113, 119, 177-178, 377-379, 468
housing and, 3, 24, 65, 187, 188, 386, 398, 467, 511
income and, 48, 118, 161, 162-163, 164, 172, 182, 184, 188, 230, 350-351, 367, 370, 383, 465, 466, 504
language proficiency and, 56, 71, 119, 167, 173-174, 175, 176, 375, 376, 503
living alone and, 61, 120, 179-180, 380, 382
marital/partnership status and, 60, 120, 178-179, 324, 379, 382
Medicare quality measure examples, 116, 150
occupation and, 118, 161, 165, 185
race and ethnicity and, 55, 100, 113, 118, 119, 121, 142, 147, 159, 167, 168, 170-172, 184, 191-192, 335, 349, 350, 365, 374, 394, 495
sexual orientation and, 10, 59, 119, 177-178, 378-379, 468
social support and, 60, 120, 180-181, 273, 324, 381, 382, 383, 510
urbanicity/rurality and, 188-189, 385, 507
wealth and, 53, 162, 319, 370, 373, 466, 508
Health and Retirement Study (HRS), 53, 54, 460, 490, 508-509, 523, 524
Health care outcomes, defined, 33
Health care use, defined, 33
Health equity
accountability for, 17, 249, 264, 268-271
accounting for social risk factors and, 3, 4, 5, 17, 18, 20, 103-104
case study, 266-267
culture of equity, 249, 263, 264-271
designing interventions to reduce inequities, 17, 18, 24, 92, 265
health information technology and, 268, 273, 277
integration into strategic planning, 249, 262, 263, 265, 269
payment policies and, 24, 83, 249
provider collaboration with outside organizations to improve, 26-27, 102-104, 233, 244, 253-254, 261, 277, 278-280, 290-291
quality improvement, 3, 17, 18
redesigning care to promote, 249, 262, 263, 264, 265-269, 275, 276, 278, 417
research needs, 18
resource alignment and allocation, 249, 263-264, 278
workforce investments to promote, 249, 263, 264-265
Health information technology (HIT), 56 n.6, 268, 273, 277, 278, 281, 287, 417, 459, 485, 487 (see also Electronic health record data)
Health insurance plans (see Insurance coverage; Medicaid; Medicare; Value-based payment in Medicare)
Health literacy
and clinical processes of care, 121, 160, 191, 268, 281-282, 388
and compensation of providers, 325, 354, 389
and cost of care, 121, 160, 190, 191, 388
defined, 69, 121, 325, 387, 400
educational attainment and, 12, 49, 69, 325, 387-388
exclusion as indicator, 10, 12, 69, 389, 400
and health and outcomes of care, 121, 160, 190-191, 335, 388, 389, 495
and patient experience, 121, 160, 191, 388
and patient safety, 160
rationale for inclusion in study, 32, 69, 112, 121, 142, 145, 146, 147, 190, 220, 231, 232, 237, 316, 318, 338, 339, 387-388, 478
and utilization of health care, 121, 190-191, 388
Health outcomes, defined, 33
Health Resources and Services Administration, 276, 279
Healthcare Effectiveness and Data Information Set (HEDIS), 93
Home health care, 126, 172, 281, 416, 483
Home Health Outcome Assessment Information Set, 61, 510
Home Health Prospective Payment Final Rule, 138, 414
Home Health Value-Based Purchasing, 110, 132-133, 138-139, 327, 414
Hospital-Acquired Condition Payment Reduction program, 110, 128, 135, 208, 326, 411
Hospital Consumer Assessment of Healthcare Providers and Suppliers (HCAHPS) survey, 128, 208-209, 353
Hospital inpatient care
community benefit/charity care requirement, 26-27, 277
Hospital-Acquired Condition Payment Reduction program, 135, 208
Hospital Readmissions Reduction Program (HRRP), 15, 27, 30, 79, 92-96, 110, 128-129, 134, 139, 140, 144, 207, 219, 230, 326, 411
Hospital Value-Based Purchasing program, 95, 110, 128, 135, 140, 208-209, 326, 411-412
Medicare Part A, 126, 127, 136, 137, 413
value-based payment (VBP) programs, 134-135, 207-209
Veterans Affairs (VA) hospitals, 172-173, 177
Hospital Readmissions Reduction Program (HRRP), 15, 79, 92-96, 110, 128-129, 134, 139, 140, 144, 207, 219, 230, 411
Housing
accounting for, in payment systems, 326, 389-390, 398-399, 457, 479, 526, 536
data sources and collection, 65, 386, 398, 458, 460, 467, 484, 489, 496, 508, 510-511, 526, 539
health and health care, 3, 24, 65, 187, 188, 386, 398, 467, 511
health system interventions, 26, 27, 253-254, 261, 277, 278-280, 290-291
measures of, 65, 324, 386, 387, 467, 510-511, 526, 539
recommendations, 65, 467, 510-511, 539
research needs, 100, 510-511, 539
residential built environment, 66, 120, 181, 187, 188, 384, 398-399, 506, 513
responsibility for improving, 355-356
and utilization of health services, 186, 187, 290, 386
I
Identifying social risk factors
conceptual framework, 8-9, 33-34, 50-51, 147-149
definitions, 33
selection criteria, 5-6, 10, 12, 35-36
Immigrants/immigration (see Acculturation; Language barriers/proficiency; Nativity)
Improving Medicare Post-Acute Care Treatment (IMPACT) Act, 4, 12, 31, 69, 110, 112, 121, 127, 138, 144, 145, 147, 190, 220, 230-231, 316, 325, 338, 387-388, 410, 456-457, 476, 477
Income
area-level as proxy for individual-level, 10, 38, 49, 52, 57, 62-63, 100, 120, 181-184, 383-384, 459, 460, 465, 488, 489, 503, 505, 506, 507, 520, 521
data sources and collection, 48-49, 162-163, 367, 460, 465, 469, 481, 487, 488, 501, 504-505, 507, 514, 520-521, 523
disability and, 70, 149, 162, 365, 371, 504
dual eligibility proxy for, 52, 68, 100, 117, 161, 371, 372, 392, 500
education and, 49, 118, 162, 164, 367, 373, 465, 504, 506
and health and health care, 48, 118, 161, 162-163, 164, 172, 182, 184, 188, 230, 350-351, 367, 370, 383, 465, 466, 504
and health equity, 23, 345, 419
and housing, 48, 162, 279, 367, 504
individual-level, 36, 48-49, 52, 53, 68, 93, 126, 161, 162-163, 164, 172, 182-183, 213, 357, 365, 367-369, 370, 371, 373-374, 390-391, 392, 425, 460, 464, 465, 469, 481, 488, 489, 498, 501, 504-505, 514, 521
inequality, 188
insurance status as a proxy for, 118, 161, 163, 164, 371, 390-391
interventions for low-income patients, 279, 286, 290
measures, 29, 36, 48, 49, 162-163, 166, 367, 465, 504
and Medicare premiums and subsidies, 126-127, 138, 213, 505
and nutrition, 48
and patient experience, 118, 131, 133, 164, 181, 367
and patient safety, 182-183
race and ethnicity and, 55, 118, 167, 172, 374
recommendations, 463-464, 501, 538-539
residential and community context, 63, 182-183, 184-185, 188, 191, 383, 465-466, 501, 505, 507-508
stratified public reporting, 93, 424
and utilization of health services, 118, 161, 162, 164, 182, 183, 184, 188, 290, 367
value/stability as indicator, 49, 53, 93, 94, 100, 355, 357, 367, 373, 389, 390-391, 392, 424-425, 457, 463-464, 479, 495, 498, 536
wealth and, 53, 54, 55, 118, 162, 167, 183, 370, 374, 466, 508, 509, 522
Indicators of social risk factors (see also specific indicators)
marginal gains from including, 100-101, 460, 461, 496, 497, 539
relative importance, 10
Inpatient Prospective Payment System, 92, 134, 411
Insurance coverage (see also Dual eligibility; Health insurance plans; Medicare)
income and, 161, 163, 164, 371, 390-391
providers disproportionately serving socially at-risk populations and, 28
as proxy for socioeconomic position, 117, 161
and unintended consequences of accounting for social risk factors, 28
L
Language barriers/proficiency
acculturation and, 58, 376, 392, 512, 526, 527
Centers for Medicare & Medicaid Services (CMS) Strategic Language Access Plan, 56, 502
and clinical processes of care, 119, 173-174, 175
community context, 55, 62, 182, 260, 290, 383, 398, 465, 506, 538-539
and costs of health care, 174
data sources and collection, 7, 10, 38, 56-57, 100, 271, 319, 375, 458, 459, 463-464, 468, 469, 481, 483, 484, 485, 502-503, 514, 517, 518-519, 526, 527, 538-539
and health and health care, 56, 71, 119, 167, 173-174, 175, 176, 375, 376, 503
and health literacy, 325, 387-388, 401
interpreter use and effects, 35-36, 71, 174, 175, 249, 264, 266, 267, 304
limited English proficiency, 32, 56, 62, 119, 129, 131, 142, 146, 167, 173-175, 232, 274, 290, 319, 339, 375, 376, 392, 464, 478, 502, 503, 519
nativity and, 175, 176, 376, 517
and patient experience, 119, 129, 131, 133, 174-175, 176-177
preferred language, 35, 56, 57, 58, 100, 176-177, 266, 464, 481, 484, 485, 502, 503, 512, 518
race and ethnicity and, 55, 118, 167, 374, 394
recommendations, 10, 463-464, 468, 501, 514, 538-539
standards, 56-57, 100, 266, 271, 375, 464, 481-482, 484, 485, 502, 503, 518-519
and utilization of health services, 119, 174, 176
value/stability as indicator, 38, 129, 131, 133, 135, 142, 326, 355, 375, 376-377, 389, 392, 394, 457, 459, 461, 479, 495, 498, 536
Living alone
and clinical processes of care, 120, 180, 380
data sources and collection, 61, 466, 508, 509-510, 524-525, 539
and health and health care, 61, 120, 179-180, 380, 382
measures of status, 61, 179, 381, 382, 508, 509
recommendations, 466, 508, 539
regional context, 381, 397, 402
and social support, 61, 354, 380, 382, 509
and utilization of health care, 120, 180, 380
value/stability as indicator, 7, 60, 61, 326, 354-355, 379, 380-381, 389, 396-397, 457, 465, 466, 479, 496, 504, 508, 521, 536, 539
M
Marital/partnership status
and clinical processes of care, 120, 179, 379
community of residence and, 60, 380
data sources and collection, 60, 463-465, 501, 503-504, 520-521, 538, 539
and health and health care, 60, 120, 178-179, 324, 379, 382
measures of status, 60, 324, 380, 382, 503
and patient experience, 120, 179, 379
race and ethnicity and, 60, 380
recommendations, 463-464, 501, 538, 539
research needs, 60-61, 464, 465, 504, 538, 539
same-sex marriage, 60, 503-504
and social support, 60, 354, 379, 396, 464-465, 503, 504
socioeconomic position and, 60, 380
and utilization of health care, 120, 179, 379
value/stability as indicator, 7, 60-61, 324, 326, 354-355, 379, 380, 382, 389, 396-397, 461, 463-465, 479, 496, 498, 501, 521, 536, 538, 539
Medicaid patients, 52, 53-65, 131, 133, 136, 163-164, 212, 231, 237, 238, 239-240, 262, 273, 278, 279, 316, 336, 371, 482, 509, 522 (see also Dual eligibility)
Medically Complex Medical Home, 281, 282, 307, 308
Medicare (see also Centers for Medicare & Medicaid Services; Value-based payment in Medicare)
Advantage/Part C, 93, 110, 116, 126, 127, 132-133, 137, 150, 212-213, 221, 233, 240, 289, 315, 327, 409, 410-411, 413, 418, 432
Current Beneficiary Survey, 61, 102, 186, 482-483, 509-510
deductibles and coinsurance, 127
Five-Star Quality Rating System, 137, 212, 221, 240, 327, 418
Hospital Compare, 221, 233, 240, 241
Income Related Monthly Adjustment Amounts, 505
overview of program, 125-127
Part A, 126, 127, 136, 137, 413
Part B, 126, 127, 136, 137, 413, 415, 465, 505
Part D, 93, 110, 116, 126, 132-133, 137, 138, 150, 163, 173, 212, 213, 221, 233, 240, 315, 327, 409, 410-411, 413-414, 465, 505
premium costs, 126-127
supplemental insurance (Medigap), 127
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), 110, 127, 327, 410, 415
Medicare Improvements for Patients and Providers Act (MIPPA), 136-137, 211, 412
Medicare Payment Advisory Commission (MedPAC), 27, 112, 140, 144
Medicare Premier Hospital Quality Incentive Demonstration, 141
Medicare Shared Savings Program (MSSP), 110, 128-129, 135-136, 209-210, 326, 412-413
Merit-Based Incentive Payment System (MIPS), 131, 211, 415
Methods to account for social risk factors (see also Unintended consequences of accounting for social risk factors)
accuracy of performance scores, 15, 35, 83, 84
between-provider adjustments and, 14, 81-83, 88, 89, 330, 436
between-provider differences, 81, 426-427
bonus for low disparities, 15, 84, 86, 90, 110 n.1, 330, 432-433, 434
categories of methods, 12-17, 329, 421-422
combining approaches, 2, 14, 15, 16, 19-20, 78, 79, 84, 90, 93, 94, 95, 99, 105, 330-331, 434-435, 436-437, 537
committee approach, 77-79, 328-329
confounders, 111, 143, 330, 331, 344-345, 349, 350, 423, 435, 445
cost considerations, 79, 331, 425, 427, 429, 431, 433
current programs, 411-414
direct adjustment of payment, 12, 13, 14-15, 16, 78, 79, 83-84, 86-87, 88-89, 92, 94, 95, 142, 329, 330, 422-423, 428-429, 434
downweight social risk factor-sensitive measures, 330, 432-433, 434
drivers of differences in quality by social risk factors, 420-421
example, 436-437
formula unadjusted for measured performance, 83, 330, 428-429, 434
goals, 5, 16, 19-20, 77, 86-87, 91, 328, 329, 420-421
in Hospital Readmissions Reduction Program (HRRP) context, 93-96
improvement relative to own benchmark, 15, 84, 86, 329, 330, 422, 430-431
incentive design in Medicare payment programs, 410-417
innovative payment models, 415-417
mitigating unintended consequences, 84-92
monitoring effects of, 7, 14, 16, 37-38, 80, 85, 91, 251, 269-270, 271, 281, 305, 331-332, 352, 359, 380, 423, 424, 438-439, 446, 456, 476, 537-538
patient characteristics within reporting units and, 13, 14, 15, 16, 80-81, 83, 84, 89, 90, 91, 329, 423, 424-425
payment adjustment, 30, 92, 111, 112, 129, 136, 138, 141, 142, 145, 207, 209, 211-212, 325 n.2, 337, 352, 387 n.1, 414, 415, 423
performance measure score adjustment, 3, 12, 13, 14, 16, 30, 78-79, 81-83, 86-87, 88-89, 91, 92, 93-94, 95, 329, 330, 422, 423, 426-427, 436-437, 496
previous recommendations, 144-145
prior conclusions, 537-538
for public reporting, 2, 14, 15, 16, 19-20, 78, 79, 84, 90, 93, 94, 95, 99, 105, 112, 330-331, 434-435, 436-437, 537
quality measures for performance added for at-risk groups, 426-427
reporting unit characteristics and, 80, 81, 87, 89, 90, 329-330, 423, 424-425
restructuring payment incentive design, 12, 13, 15-16, 78, 79, 86-87, 90-92, 94, 95-96, 430-433
risk adjustment of performance measures, 111-112, 141, 142-144, 423, 426-427
stratification of benchmarks used for payment, 83, 428-429
stratified public reporting, 12, 13-14, 15, 16, 78-81, 83, 84, 86-89, 91, 92, 93, 94, 95, 271, 274-275, 423, 424-425, 436-437
within-provider differences, 14, 16, 81-82, 83, 88, 89, 90, 94, 330, 423, 426-427, 435, 436, 437
Minority-serving institutions, 27, 80, 140, 220-221, 233, 237, 238-239, 240, 244, 335, 336, 418
black-serving institutions, 238
Monitoring disparities, 7, 14, 16, 37-38, 80, 85, 91, 251, 269-270, 271, 281, 305, 331-332, 352, 359, 380, 423, 424, 438-439, 446, 456, 476, 537-538
N
National Health and Aging Trends Study (NHATS), 460, 490
National Health and Nutrition Examination Survey (NHANES), 68, 460, 488, 490, 513, 528
National Health Interview Survey (NHIS), 68, 377, 460, 490, 513, 528
National Healthcare Safety Network (NHSN), 128, 132, 135, 137, 208, 209, 411, 412
National Institute on Aging, 490
National Quality Forum (NQF), 36, 92, 112, 132, 144, 207, 213-214, 317-318, 348, 445, 449-450
National Survey of Family Growth (NSFG), 377, 460, 490, 528
National Survey on Drug Use and Health, 377
Nativity
and clinical processes of care, 119, 176-177, 376
and costs of care, 176
data sources and collection, 57-58, 100, 376, 395, 463, 469, 487, 499, 500, 514, 516-517, 538
defined, 57, 175, 375, 394, 463, 500
and health and health care, 175, 176, 376
and patient experience, 119, 176-177, 376
proxy for acculturation, 57, 376
race and ethnicity and, 118, 167, 374, 376, 394-395
and utilization of health services, 176
value/stability as indicator, 319, 326, 355, 376, 389, 394, 457, 461, 463, 479, 495, 498, 500, 536
Neighborhood deprivation/disadvantage
and community compositional characteristics, 62-63, 182, 324, 383, 387, 398, 465, 506
data sources and collection, 63, 387, 463-464, 465, 501, 506-507, 508, 522-523
and health care resources, 140, 188, 507
and hospital performance, 140
measurement of, 62-63, 182, 324, 465-466, 506, 507, 508, 523
proxy for individual- and area-level constructs, 63, 324, 387, 402, 464, 465, 506
recommendation, 63, 463-464, 501, 507-508, 538-539
research suggestion, 63, 100, 464, 466, 508
urban versus rural, 507-508, 523
and utilization of health care, 183-184, 188
value/stability as indicator, 326, 383, 387, 389, 457, 479, 496, 501, 507-508, 536, 538-539
Nursing Home Value-Based Purchasing Demonstration, 127 n.1
O
Occupation (see also Employment)
and clinical processes of care, 165-166
data sources and collection, 54, 165-166, 185, 372-373
defined, 54, 117, 161, 165, 372
education and, 49, 164, 373, 465, 506
and utilization of health services, 118, 165, 185
value/stability as indicator, 54, 319, 350, 355, 372-373, 374, 390-391, 392
Office of Management and Budget (OMB), 55, 56, 375, 393, 464, 484, 502, 518
Office of Personnel Management, 49, 505
Office of the National Coordinator for Health Information Technology (ONC), 55-56, 68, 378, 458-459, 468, 484-485, 486, 510
Outpatient care (see Ambulatory care)
P
Patient-centered care, 4, 18, 24, 31, 103, 223, 224, 245, 247, 260, 262, 266, 275, 286, 287, 288-289, 290, 303, 316, 338, 477, 535
Patient experience
community context and, 121
dual eligibility and, 372
educational attainment and, 118, 129, 131, 133, 165
health literacy and, 160
income and, 118, 131, 133, 164, 181, 367
language proficiency and, 119, 129, 131, 133, 174-175, 176-177
marital/partnership status and, 120, 179, 379
Medicare quality measure examples, 116, 150
nativity and, 119, 176-177, 376
race and ethnicity and, 119, 167, 172-173, 374
social support and, 120, 181, 381
Patient Protection and Affordable Care Act of 2010 (ACA), 26, 110, 125, 127, 135, 136, 199, 219, 225, 274, 279, 315, 335, 410, 412-413, 445
Patient safety
Agency for Healthcare Research and Quality (AHRQ) indicators, 116, 120, 128, 135, 150, 208, 209
community composition and, 120
health literacy and, 160
income and, 182-183
Medicare quality measure examples, 116, 150
National Healthcare Safety Network indicators, 128, 132, 135, 137, 208, 209, 411, 412
race and ethnicity and, 119, 173, 374
social relationships and, 120
social support and, 181
socioeconomic position and, 118
Pay-for-performance, 24, 109, 125, 135, 136, 141, 315, 335, 410, 412, 418, 455 n.1, 475 n.1
Payment (see Value-based payment in Medicare)
Performance indicators used in value-based payment
clinical processes of care, 3-4, 8-9, 33, 34-35, 50-51, 114, 115, 116, 118, 119, 120, 121, 128, 132, 135, 138, 141, 147, 148, 149, 150, 160, 162, 164, 165-166, 169-170, 173-174, 175, 176-177, 178, 179, 180, 181, 184-185, 186, 189, 190, 191, 208-209, 220, 241, 268, 281-282, 322-323, 344, 367, 368-369, 372, 374, 376, 379, 380, 381, 382, 383, 385, 388, 412
costs of care, 8-9, 14, 17, 33, 34-35, 50-51, 69, 79, 83, 102, 111, 114, 115, 116, 118, 119, 120, 121, 130-132, 136, 138, 139, 141, 142, 147, 148, 149, 150, 160, 162, 163, 164, 168, 173, 174, 175, 179, 182, 183, 189, 190, 191, 210, 211, 212, 213, 225, 260, 277, 280, 322-323, 330, 331, 344, 367, 368-389, 374, 379, 385, 388, 412, 413, 418, 424-433, 438, 469, 514
health care outcomes, 3, 8-9, 10, 24, 33, 34-35, 36, 48, 49, 50-51, 52, 53, 55, 56, 57, 58, 59, 60, 61, 65, 69, 71, 100, 102, 111, 113, 114, 115, 116, 118, 119, 120, 121, 142, 147, 148, 150, 159, 160, 161, 162-163, 164, 165, 167, 168, 170-172, 173-174, 175, 176, 177-181, 182, 183, 184, 187, 188, 189, 190-192, 230, 273, 284, 318, 319, 320, 322-323, 324, 335, 344, 345, 348, 349-353, 360, 365, 367, 368-369, 370, 371, 372, 373, 374, 375, 376, 377-379, 380, 381, 382, 383, 384, 385, 386, 387, 388, 389, 390, 391, 392, 394, 396, 398, 400, 449, 465, 466, 467-468, 495, 503, 504, 505-506, 507, 508, 510, 511-512, 536
health care use and utilization, 8-9, 33, 34-35, 50-51, 69, 102, 114, 115, 116, 118, 119, 120, 121, 147, 148, 149, 150, 161, 162, 163, 164-165, 166, 168-169, 173, 174, 175, 176, 179, 180, 181, 182, 183-184, 185, 186, 187, 188, 189, 190-192, 267, 279, 290, 322-323, 325 n.2, 344, 350, 365, 367, 368-369, 372, 373, 374, 379, 380, 381, 383, 385, 386, 387 n.1, 388
patient experience, 8-9, 33, 34-35, 50-51, 114, 115-116, 118, 119, 120, 121, 128, 129, 131, 132, 133, 135, 138-139, 147, 148, 150, 160, 162, 163, 164, 165, 166, 167, 168, 172-173, 174-175, 176-177, 178, 179, 181, 187, 189, 190, 191, 208, 209, 219, 238, 241, 260, 265, 268, 275, 280, 322-323, 344, 367, 368-369, 372, 373, 374, 376, 379, 381, 385, 388, 411, 412, 483
patient safety, 8-9, 33, 34-35, 50-51, 114, 115, 116, 118, 119, 120, 128, 130, 132, 135, 137, 138, 147, 148, 150, 160, 162-163, 166, 173, 181, 182-183, 186, 208, 209, 210, 238, 239, 322-323, 344, 368-369, 374, 383, 411, 412, 432, 487
resource use, 8-9, 13, 14, 32, 33, 34-35, 48, 50-51, 79, 83, 112, 113-114, 115, 116, 118, 144-145, 146, 147, 148, 149, 150, 230-231, 232, 322-323, 325 n.2, 331, 339, 344, 365, 366, 368-369, 387 n.1, 415, 438, 478, 537
Physician Quality Reporting System, 136, 211, 412, 415
Physician Value-Based Modifier, 130-131, 136, 210-211, 326, 412, 415
Population health, defined, 25, 268
Post-acute care
home health, 110, 132-133, 138-139, 327, 414
skilled nursing facilities, 110, 112-113, 138, 213-214, 327, 414
value-based payment (VBP) programs, 138-139, 213-214
Providers disproportionately serving socially at-risk populations
ambulatory care, 27, 140, 221, 239-240, 336
best practices, 222-223, 244 (see also Systems practices)
community health centers, 221, 233, 237, 239, 240, 276, 278, 306, 335-336, 418, 486
critical access hospitals, 27, 220-221, 233, 237, 239, 335-336, 418, 486
direct payments for quality improvement, 18, 94, 105
direct payments to incentivize collaborations, 18, 105
electronic health records, 486-487
inpatient care, 27, 139-140, 221, 237-239
interventions to improve care (see Systems practices)
minority-serving institutions, 27, 80, 140, 220-221, 233, 237, 238-239, 240, 244, 335, 336, 418
outcomes of care, 221
performance measure score adjustment, 81, 82, 83, 94, 111-112
performance/quality variation, 3, 27, 82, 85, 103, 140, 141, 219, 220-222, 229, 237-241, 336
publicly reported performance data, 221, 240-241
restructuring payment incentive design, 94
revenues/resources under quality incentive schemes, 27-28, 83, 84, 103, 105, 112, 139-140, 141, 230, 242, 336, 418
safety-net providers, 1, 18, 27, 30, 80, 81, 87, 89, 94, 105, 140, 209, 219, 220-221, 225, 230, 233, 237, 238, 239, 263, 265, 266, 270, 272, 278, 287, 329, 335, 336, 418, 424, 428, 486
status quo under current value-based payment (VBP) programs, and, 28-29, 82
stratification by reporting unit characteristics, 60, 80
uninsured patient care, 28, 52, 163, 237, 238, 239, 273, 276, 286, 316, 336, 371
unintended consequences of the status quo of value-based payment (VBP) programs, 3-4, 14, 27-28, 83, 84, 103, 105, 111-112, 139-140, 141, 142, 229, 230, 242, 336, 418, 435
R
Race and ethnicity
and access to care, 167-168
acculturation and, 58, 376, 394-395, 512
categorization issues, 55, 167, 374-375, 393
and clinical processes of care, 119, 169-170, 173, 191, 374
comparability/standardization of data, 55, 56, 57, 118, 167, 271, 374, 393, 481-482, 502 and costs of care, 119, 121, 173, 191-192, 374
data sources and collection, 7, 10, 37, 38, 39, 55-56, 266, 271, 375, 457, 458, 463-464, 468, 469, 481-482, 483, 484, 485, 501, 502, 514, 515, 518-519, 538-539
definition and constructs, 6, 118, 374, 464, 501-502
and disability benefits, 70
and discrimination, 118, 166-167, 374
and health and health care, 55, 100, 113, 118, 119, 121, 142, 147, 159, 167, 168, 170-172, 184, 191-192, 220, 335, 349, 350, 365, 374, 394, 495
and health care equity, 23, 119, 167-168, 262, 266, 345, 346
and immigration status, 118, 167, 374, 376, 394-395
interventions to reduce disparities, 263, 264, 265, 267, 268, 269, 270, 276, 278, 282-283, 284, 285
and language proficiency, 55, 118, 167, 394
and marital or partnership status, 60, 380
and measurement error in socioeconomic position (SEP), 118, 120, 167, 374
and measurement of performance, 93-94, 271, 318, 319, 326, 349, 355, 374, 376, 389, 392, 393, 394, 457, 463-464, 477, 479, 495, 501, 538
and neighborhood environments, 62, 118, 167, 184, 191, 374
and patient experience, 119, 167, 172-173, 374
and patient safety, 119, 173, 374
and performance of minority-serving institutions, 27, 80, 140, 141, 220-221, 229, 230, 233, 237, 238-239, 240, 244, 335, 336, 418
and quality of care, 55, 167-168, 239, 374
recommendations, 10, 37, 56, 463-464, 468, 501, 514, 538-539
self-identification and self-reporting, 38, 55, 167, 374, 457, 464, 481
and utilization of health care, 119, 121, 168-169, 173, 191-192, 242, 267, 350, 365, 374
Railroad Retirement Board, 49, 126, 505
Residential and community context (see also Neighborhood deprivation/disadvantage)
built/physical environment, 7, 62, 120, 187-188
community socioeconomic composition, 7, 62, 63, 120, 182-186, 383-384, 398-399
composite measures, 183-184, 185-186
contextual community effects, 120-121, 186-189
data sources and collection, 10, 38, 63, 513-514
disabilities and, 120
educational attainment of area/neighborhood, 63, 183, 185
environmental measures, 62-66, 384-386, 398-399, 513-514
health care resources, 187-188
housing, 63, 65, 66, 120, 181, 187, 188, 384, 398-399, 506, 513
income of area/neighborhood, 63, 182-183, 184-185, 188
measure of group-level effects, 62, 184-186
proxy for individual-level effects, 62-63, 182-184
racial/ethnic minority residents, 62, 63, 118, 120, 167, 184, 185, 191, 374
research suggestion, 63
social environment, 7, 62, 120, 188-189
transportation, 26, 27, 62, 66, 120, 181, 187, 254, 259, 271, 282, 283, 288, 290, 370, 381-382, 384, 398, 468, 506, 510, 513, 529
urbanicity/rurality, 64-65, 188-189, 326, 385, 389, 398-399
value/stability as indicator, 10, 33, 62-63
Resource use, defined (see also Costs of care), 33
Rurality (see also Urbanicity/rurality)
and access to health care. 27, 64, 189, 385, 507
and clinical processes of care, 189
critical access hospitals, 27, 220-221, 233, 237, 239, 335-336, 418, 486
data sources and collection, 63, 144, 463, 466, 501, 508, 523
defined, 64
and health and health care outcomes, 239, 507
interventions to improve care, 284-285
language issues, 189
measures and measurement issues, 64, 385, 500-501, 507, 508
and neighborhood deprivation, 63, 466, 507, 508, 523
and payment adjustments for facilities, 211
provider versus patient, 64, 385, 500
recommendation, 466
and resource use, 112
and utilization of health care, 189
S
Safety-net providers, 1, 18, 27, 30, 80, 81, 87, 89, 94, 105, 140, 209, 219, 220-221, 225, 230, 233, 237, 238, 239, 263, 265, 266, 270, 272, 278, 287, 329, 335, 336, 418, 424, 428, 486
Selection criteria for social risk factors (see also Gender; Health literacy; Indicators of social risk factors; Methods to account for social risk factors; Race and ethnicity; Residential and community context; Social relationships; Socioeconomic position)
application to social risk factors and health literacy, 316-317, 318-326, 358-359, 365-402
Centers for Medicare & Medicaid Services (CMS)-Hierarchical Condition Category (HCC) model criteria and, 445-447
committee process, 338, 340, 347-348
Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey case-mix adjustment criteria and, 448
manipulation- or gaming-resistant, 6, 36, 48, 318, 319, 321, 324, 348, 353, 356-358, 361, 366, 367, 372, 373, 374, 375, 376, 377, 380, 381, 382, 384, 385, 386, 388, 389, 390, 392, 394, 396, 398, 400, 450, 536
National Quality Forum criteria guidelines and, 449-450
outcome of interest, 36, 59, 318, 320, 344, 345, 348, 349-353, 360, 367, 375, 376, 378, 380, 381, 382, 384, 385, 387, 389, 390, 392, 394, 396, 398, 400, 449, 536
overarching considerations, 35-36, 318, 320-321, 348, 536
preceding care delivery and not modifiable by provider, 5-6, 36, 48, 318, 319, 321, 324, 348, 353-356, 361, 366, 367, 373, 374, 375, 376, 380, 381, 382, 384, 385, 387, 389, 390, 392, 394, 396, 398, 400, 536
prior conclusions, 536-537
statement of task, 316-317, 338, 339
U.S. Department of Health and Human Services (HHS)-Hierarchical Condition Category (HCC) risk adjustment model criteria and, 448-449
Sexual orientation
and clinical processes of care, 119, 178, 220
data sources and collection, 10, 59, 68-69, 324, 378, 467, 468, 485, 488, 511-513, 528-529, 539
definition and constructs, 6, 58, 319, 324, 378, 394, 468, 512
and health and health care, 10, 59, 119, 177-178, 378-379, 468
measures, 59, 378, 395, 468, 512-513
performance of providers, 220, 229, 230, 237
recommendations, 467, 511-512, 539
value/stability as indicator, 10, 59, 68, 324, 326, 378-379, 394-395, 396, 402, 457, 479, 496, 513, 537
Skilled nursing facility services, 126, 239, 282, 386, 414, 416, 417
Skilled Nursing Facility Value-Based Purchasing, 110, 112-113, 138, 213-214, 327, 414
Social relationships
constructs (see Living alone; Marital/partnership status; Social support)
and health and health care, 6-7, 59-60, 119-120
Social risk factors (see also Gender; Health literacy; Indicators; Methods to account for social risk factors; Race and ethnicity; Residential and community context; Selection criteria for social risk factors; Social relationships; Socioeconomic position)
conceptual framework, 5-7, 8-9, 50-51, 159-160, 318, 322-323, 338, 340
as confounders, 111, 143, 330, 331, 344-345, 349, 350, 423, 435, 445
definitions and literature search, 160-191
implementation considerations, 402
influence, defined, 117
interventions to address social risk factors, 26-27, 102-104, 233, 244, 253-254, 261, 277, 278-280, 290-291
pathways of influence, 159-160
prior conclusions and recommendations, 144-145, 536-537
rationale for accounting for, 343-345
Social Security Administration (SSA)
data sets, 488-489
Health and Retirement Study, 490
income data, 49, 465, 469, 504, 505, 520, 521
nativity data, 57, 58, 463, 469, 500, 514, 516, 517
race and ethnicity data, 514, 519
range of individual-level data, 10, 38, 459-460, 488-489
Social support
and access to services, 61-62, 510
and clinical processes of care, 120, 181, 381
community context, 383
data sources and collection, 62, 466, 467, 508, 510, 524-525, 539
emotional and instrumental components, 61-62, 180, 324, 379, 381-382, 466-467, 510
and health and health care, 60, 120, 180-181, 273, 324, 381, 382, 383, 510
health system interventions, 273, 381-382
living alone and, 61, 354, 380, 382, 509
marital/partnership status and, 60, 354, 379, 396, 464-465, 503, 504
measures of, 62, 181, 273, 324, 382, 397, 402, 464-465, 466, 508, 510, 539
and patient experience, 120, 181, 381
and patient safety, 181
recommendations, 466, 508, 539
and utilization of health care, 120, 180, 181, 279, 381
value/stability as indicator, 39, 61, 62, 178, 273, 324, 326, 354-355, 381-382, 396-397, 402, 457, 467, 479, 496, 508, 537
Socioeconomic position (SEP)
data sources, 161-166
indicators/measures, 48-54, 117, 161-166 (see also Dual eligibility; Education; Food sufficiency/insecurity; Income; Insurance coverage; Occupation; Wealth)
measurement issues, 29-30
and quality rankings for providers, 30, 143-144
Socioeconomic status, defined (see also Socioeconomic position), 33, 117
Statement of task, 4-5, 30-31, 32, 113-114
interpreting, 145-149
Systems practices, 244
case studies, 102-103, 222, 223, 233, 243-244, 245, 247, 262, 266, 272-273, 274, 277, 279, 282, 284, 286, 303, 304-308, 386
collaborative partnerships, 18, 26, 103, 105, 223, 225, 244, 245, 246, 247, 254-255, 261, 269, 273-274, 275-280, 290-291, 303, 306-307, 535
commitment to health equity, 2, 23, 103, 223, 224, 225, 245, 246, 248-249, 263-271, 277, 288-289, 303, 304, 345
committee process and approach, 102-103, 231-233
comprehensive needs assessment, 223, 225, 245, 246, 252-253, 268, 272-275, 288-289, 303, 305-306, 535
context for this report, 225-226, 291-292
continuity of care, 224, 225, 245, 256-257, 269, 280-281, 282, 290-291, 303, 307-308, 535
data and measurement, 223, 245, 250-251, 268, 271-272, 273, 288-289, 303, 305-306, 535
engaging patients in their care, 103, 224, 245, 247, 252, 256, 258-259, 266, 269, 280, 281-285, 286, 303, 308-309, 536
evidence base for practices, 260-285
identifying systems practices, 223-225, 233, 244-259
interventions to address social risk factors, 26-27, 102-104, 233, 244, 253-254, 261, 277, 278-280, 290-291
and patient experiences of care, 238, 241, 260, 264, 265, 266, 267, 268, 275, 280
performance of providers disproportionately serving socially at-risk populations, 220-222, 237-241
practices to improve care, 18-19, 222-223, 242-244, 248-259, 288-289, 535-536
prior conclusions, 535-536
resource and sustainability considerations, 18, 225, 287, 288-291
statement of task, 220, 231, 232
T
Transportation, 26, 27, 62, 66, 120, 181, 187, 254, 259, 271, 282, 283, 288, 290, 370, 381-382, 384, 398, 468, 506, 510, 513, 529
U
Uninsured persons, 52, 163, 237, 238, 239, 273, 276, 286, 316, 336, 371, 355-356
Unintended consequences of accounting for social risk factors
accountable care organizations (ACOs) and, 219, 229
addressing, 141-142
avoiding patients with social risk factors, 1, 4, 5, 14, 15, 28, 29, 78, 83-84, 88-91, 327, 348, 419, 435
between-provider/between-plan adjustments and, 14, 81-83, 88, 89, 330
direct adjustment of payments and, 15, 88-89, 95
disincentives to improve quality and efficiency, 5, 14, 15-16, 28, 29, 71, 78, 83, 85, 88-91, 111, 142, 327, 336, 337, 346, 347, 419, 427, 435, 476
insurance coverage denial, 418
minimizing/mitigating, 79, 84-92, 110-112, 141-142, 337
monitoring data for, 2, 37-38, 85, 91, 102, 332, 438
negative symbolic value, 5, 16, 80-81, 88-91, 328, 419
obscuring health disparities, 5, 16, 28, 29, 78, 85, 88-91, 93, 111, 139, 141, 142, 328, 337, 347, 420, 476
patient characteristics within reporting units and, 16, 81, 141-142
of performance measure score adjustment, 14, 82, 88-89, 111-112, 139-140
reporting unit characteristics and, 81
restructuring payment incentive design, 78, 90-91
standards of care, 80-81
status quo of value-based payment (VBP) programs and, 1, 2, 3-4, 28-29, 37-38, 78, 81, 82, 86, 88, 90, 95, 327-328, 337, 346, 417- 420, 435, 438, 537
of stratified public reporting, 16, 78, 80-81, 88-89
underpayment/diminished resources of safety-net providers, 3-4, 14, 27-28, 83, 84, 103, 105, 111-112, 139-140, 141, 142, 229, 230, 242, 336, 418, 435
Urbanicity/rurality (see also Rurality)
and access to health care, 189, 385
built environment, 187
categories, 188-189
and clinical processes of care, 121, 189, 385
and costs of health care, 121, 189, 385
data sources and collection, 64, 100, 463, 499, 501, 506, 516-517, 523, 538
defined, 64, 385, 398, 463, 500
and health and health care, 188-189, 385, 507
and health care resources, 189
measures and measurement issues, 64, 324, 385, 387, 399, 463, 500-501, 507, 528
and neighborhood deprivation, 189, 385, 506, 507, 523
and patient experience, 121, 189, 385
and payment adjustments for hospitals, 209
provider versus patient, 64, 385, 500
and quality of care, 209, 239, 385
residential and community context, 64-65, 188-189, 326, 385, 389, 398-399
social environment, 188
and utilization of health care, 121, 189, 385
value/stability as indicator, 326, 385, 389, 398-399, 457, 479, 496, 499, 538
U.S. Census Bureau data, 63, 64-65, 100, 324, 325 n.2, 383, 385, 387, 398, 460, 463, 466, 489, 501, 506, 507-508, 516, 517, 523
U.S. Department of Health and Human Services (HHS)
gender identity data, 58
Office for Civil Rights, 57, 503
payment goals for Centers for Medicare & Medicaid Services (CMS), 25
standards for racial categories, 55
U.S. Department of Housing and Urban Development (HUD), 386, 467, 526
Healthy Communities Index, 65, 511
U.S. Department of Veterans Affairs (VA), 172
Utilization of health care services
community composition and, 120
community context and, 121
education and, 118, 161, 164-165, 183, 185
health literacy and, 121, 190-191, 388
housing and, 186, 187, 290, 386
income and, 118, 161, 162, 164, 182, 183, 184, 188, 290, 367
language proficiency and, 119, 174, 176
living alone and, 120, 180, 380
marital/partnership status and, 120, 179, 379
Medicare quality measure examples, 116, 150
nativity and, 176
neighborhood deprivation and, 183-184, 188
race and ethnicity and, 119, 121, 168-169, 173, 191-192, 267, 350, 365, 374
social support and, 120, 180, 181, 279, 381
urbanicity/rurality and, 121, 189, 385
V
Value-based payment in Medicare (see also Medicare; Methods to account for social risk factors; Unintended consequences of accounting for social risk factors)
for ambulatory care, 135-137, 209-212
bonus payments, 3, 15, 24, 27, 84, 86, 90, 110 n.1, 129, 132, 137 n.4, 140, 209, 212-213, 315, 327, 330, 410, 413, 418, 428, 432-433, 434, 437, 455, 475 n.1, 485
bundled payments, 24-25, 109, 125, 137, 219, 315, 327, 335, 410, 416, 434
Bundled Payments for Care Improvement (BPCI) Initiative, 110 n.1, 127 n.1, 335, 415, 416
Centers for Medicare & Medicaid Services goals, 25, 409, 410
clinical process measures, 116, 128, 135, 208-209, 241
committee process, 115, 117, 149-151
Comprehensive Primary Care Plus, 327, 417
current programs, 110, 127-139, 411-414
data on social risk factors, 458, 482
domains of performance indicators, 33
with downside risk, 110, 130-131, 136-137, 211-212, 326, 412-413
End-Stage Renal Disease Quality Improvement Program, 110, 130-131, 136-137, 211-212, 326, 412-413
future directions, 139
goals, 3, 24, 25, 77, 109, 414-415
for health plans, 137-138, 212-213
Home Health Value-Based Purchasing, 110, 132-133, 138-139, 327, 414
Hospital-Acquired Condition Payment Reduction program, 110, 128, 135, 208, 326, 411
hospital inpatient care, 134-135, 207-209
Hospital Readmissions Reduction Program, 15, 27, 30, 79, 92-96, 110, 128-129, 134, 139, 140, 144, 207, 219, 230, 326, 411
Hospital Value-Based Purchasing program, 95, 110, 128, 135, 140, 208-209, 326, 411-412
incentive payments for participation in, 415
innovative models under testing, 327
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), 110, 127, 327, 410, 415
Medicare Advantage/Part C, 93, 110, 116, 126, 127, 132-133, 137, 150, 212-213, 221, 233, 240, 289, 315, 327, 409, 410-411, 413, 418, 432
Medicare Part D, 93, 110, 116, 126, 132-133, 137, 138, 150, 163, 173, 212, 213, 221, 233, 240, 315, 327, 409, 410-411, 413-414, 465, 505
Medicare Shared Savings Program, 110, 128-129, 135-136, 209-210, 326, 412-413
monitoring disparities, 80
Next Generation Accountable Care Organizations (ACOs), 327, 415, 416-417
overview of programs, 115, 117, 207
patient safety measures, 116, 120, 128, 132, 135, 137, 150, 208, 209, 411, 412
pay-for-performance, 24, 109, 125, 135, 136, 141, 315, 335, 410, 412, 418, 455 n.1, 475 n.1
Physician Value-Based Modifier, 136, 210-211, 326, 412, 415
population-based payments, 287, 315, 327, 409, 410, 434, 455
population health approach, 25
for post-acute care, 138-139
and provider risk, 24-25, 125, 315, 335, 455, 475
and racial disparities, 141
readmission measures, 92, 132, 207, 213-214, 414
reinsurance, 138, 213, 327, 413
risk corridors, 110 n.1, 133, 137 n.4, 138, 213, 327, 413-414
Skilled Nursing Facility Value-Based Purchasing, 110, 112-113, 138, 213-214, 327, 414
statement of task, 113-114, 115-116
threshold-based, 82-83
unintended consequences of status quo, 1, 2, 3-4, 28-29, 37-38, 78, 81, 82, 86, 88, 90, 95, 229, 327-328, 337, 346, 417- 420, 434-435, 438, 537
with upside gainsharing and downside risk, 110, 128-129, 135-136, 209-210, 326, 412-413
W
Wealth
data sources and collection, 53-54, 466, 490, 496, 508-509, 522-523
disabilities and, 162, 371, 372
dual eligibility as proxy, 52, 53-54, 68, 371, 372, 500, 509, 522
and health and health care, 53, 162, 319, 370, 373, 466, 508
and income, 53, 54, 55, 118, 162, 167, 183, 370, 374, 466, 508, 509, 522
measures, 53, 370, 466, 508, 539
race and ethnicity and, 53, 55, 167, 370, 374
recommendations, 466, 508, 539
value/stability as indicator, 48, 53, 117, 161, 319, 326, 355, 370, 390-391, 402, 457, 479, 495, 496, 498, 508, 537, 539
