Accounting for Social Risk Factors in Medicare Payment Identifying Social Risk Factors (2016) / Chapter Skim
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1 Introduction
1 Introduction
Pages 15-46
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. Specific payment strategies include pay-for-performance and other quality incentive programs that tie financial rewards and sanctions to the quality and efficiency of care provided, and risk-based alternative payment models (APMs)
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. The health status of Medicare beneficiaries, even within those who began Medicare coverage on the basis of age, varies widely.
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and the Medicare Access and CHIP Reauthorization Act of 2015 require CMS to implement VBP programs for Medicare inpatient hospital care, ambulatory care, health plans, and post-acute care. Currently, there are eight VBP programs in Medicare, with two post-acute care programs in proposal or planning.3 These programs are summarized below and in Table 1-1.
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(HAC) of 1% of all CDC NHSN infection measuresf Payment discharge payments Reductione
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) Medicare ACO expenditures above/below Demographics; case-mix; For performance year 2014, 92 MSSP Shared Savings benchmarks disease severity ACOs held spending to $806 million Programk below their benchmarks, resulting in $341 million in payments to the ACOs and a net savings of $465 for the Medicare Trust Funds.
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met minimum community/population health; Medicaid status, low-income Among these, 14 groups received reporting patient safety; communication subsidy, Asian language upward adjustments for performance, requirements) : Value and care coordination; and survey (Cantonese/Korean/ 81 received no adjustments, 11 modifier calculated efficiency and cost reduction)
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and reporting dialysis method 0.6% a 2.0% reduction.u measures Patient experience: survey mode; overall health; overall mental health; heart disease; deaf or serious difficulty hearing; blind or serious difficulty seeing; difficulty concentrating, remembering, or making decisions; difficulty dressing or bathing; age; sex; education; speaks language other than English at home; did someone help the patient complete the survey; total years on dialysis s Also adjusted for volume, geographic factors, wage indext
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status, disabled status, and working aged status Patient experience: age, education, general health status, mental health status, survey mode (proxy helped or answered) , Medicaid status, low-income subsidy, and Chinese language survey w Medicare Part Bonus payments or Star Quality Ratings (for MA Age, education, general Nearly 75% of plans pay a portion of Dx rebates for MA Part Part D plans, Part D Star Rating health status, mental health their profits to Medicare each year D plans contributes to overall plan status, survey mode (proxy under risk corridors; between 2010 rating)
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l CMS, 2015i. m Unless indicated otherwise, the information in this row is from CMS, n.d.-c.
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bb Unless indicated otherwise, information in this row is from HHS, 2015.
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. Hospital-Acquired Condition Payment Reduction The Hospital-Acquired Condition Payment Reduction program requires the Secretary of Health and Human Services to reduce payments to acute care hospitals paid under the IPPS based on their performance on select risk-adjusted hospital-acquired condition (HAC)
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At the end of each performance period, CMS compares MSSP ACOs' actual spending to the calculated benchmark. As of January 1, 2015, 404 ACOs covering 7.92 million Medicare beneficiaries in 49 states; Washington, DC; and Puerto Rico entered into a Shared Savings Program agreement with CMS (CMS, 2015d)
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. Medicare Value-Based Payment Programs for Health Plans4 Medicare Advantage/Part C As described in the previous section, MA or Medicare Part C is the insurance program that covers the Part A and Part B benefits, typically offers Part D prescription drug coverage, and may offer additional benefits and services at additional cost (MedPAC, 2015b)
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. In its proposal, CMS identified possible quality measures covering clinical processes, clinical outcomes, patient safety, patient and caregiver experience, population/community health, and efficiency and cost reduction for use in the program.
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. Several studies have shown that larger hospitals, teaching hospitals, and safety-net hospitals, which traditionally serve more disadvantaged patients, are more likely to rank poorly on quality measures and therefore are more likely to be penalized under Medicare VBP programs (Berenson and Shih, 2012; Gilman et al., 2014, 2015; Joynt and Jha, 2013; Rajaram et al., 2015)
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Improving Value-Based Payment to Address Unintended Consequences While the impact of value-based purchasing strategies on providers serving vulnerable populations and on health disparities continues to be monitored both under Medicare and more widely, and because more VBP programs are being implemented and existing programs are expanding, some methods have been proposed to improve these payment programs to address the potential unintended consequences on vulnerable populations and disparities. Chief among methods proposed to improve VBP to address these unintended consequences is accounting for differences in patient characteristics when measuring quality and calculating payments, sometimes referred to as risk adjustment or payment adjustment.
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In other words, risk adjustment can include social factors for the purposes of measurement accuracy without affecting payment. Similarly, payment adjustment can be done by basing payment on measures that are risk adjusted or through other methods, such as directly funding programs to improve the quality of care for disadvantaged patients (Berenson and Shih, 2012)
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. Previous Recommendations for Accounting for Social Risk Factors in Medicare Payment Programs In light of this debate, two expert panels have previously examined whether to include social risk factors in risk adjustment for Medicare payment models and offered recommendations.
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to convene an ad hoc committee to provide a definition of SES for the purposes of application to Medicare quality measurement and payment programs; to identify the social factors that have been shown to impact health outcomes of Medicare beneficiaries; and to specify criteria that could be used in determining which social factors should be accounted for in Medicare quality measurement and payment programs. Furthermore, the committee will identify methods that could be used in the application of these social factors to quality measurement and/or payment methodologies.
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that could potentially be used to determine whether an SES factor or other social factor should be accounted for in Medicare quality, resource use, or other measures used in Medicare payment programs. • Identify SES factors or other social factors that could be incorporated into quality, resource use, or other measures used in Medicare payment programs.
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Additionally, although the statement of task specifies only examining the impact of these social risk factors on "health outcomes," it also specifies that the social risk factors should be targeted "for the purpose of application to quality, resource use, or other measures used for Medicare payment programs." Thus, given the importance that Medicare VBP programs has placed on this broader set of measures and given that Medicare applies these measures when calculating payments, the committee interpreted "health outcomes" as encompassing measures of health care use, health care outcomes, and resource use. Hence, the committee included two domains of health care use measures (health care utilization and clinical processes of care)
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3 36 ACCOUNT TING FOR SOC CIAL RISK FAC CTORS IN MEDI ICARE PAYME ENT F FIGURE 1-1 Conceptual framewo of social risk factors for health care use, outcom and cost. ork h mes, N NOTE: This conc ceptual framewor illustrates prim rk mary hypothesized conceptual relat d tionships.
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. Any variation in the effect of social risk factors among disabled Medicare beneficiaries under age 65, Medicare beneficiaries age 65 and older, and beneficiaries with ESRD is considered to fall within a continuous spectrum of effects.
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• Central line-acquired bloodstream infection • Catheter-acquired urinary tract infection • Surgical site infection • Incidence of major falls for post-acute care patients Patient Experience • Communication with nurses • Communication with doctors • Getting timely appointments, care, and information • Getting information from Part D drug plan • Helpful, courteous, and respectful office staff • Responsiveness of hospital staff • Care coordination • Pain management • Communication about medications • Cleanliness and quietness • Overall rating of hospital • Overall rating of Medicare Advantage health plan NOTE: AHRQ = Agency for Healthcare Research and Quality; AMI = acute myocardial infarction; COPD = chronic obstructive pulmonary disease.
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The identification and description of the literature should not be mistaken for a systematic review that uses a formal system for weighing and describing evidence, such as those used in clinical or public health guideline development. The committee's interpretation of the task for report one was to define SES for the purposes of application to Medicare payment programs and to identify whether there exists literature showing an influence of one or more social risk factors on one or more measures of relevant health care use or outcomes.
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2014a. End-Stage Renal Disease Quality Incentive Program payment year 2016 program details.
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2015d. Fast facts: All Medicare shared savings program (shared savings program)
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2015. Accounting for socioeconomic status in Medicare payment programs: ASPE's work under the impact act.
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2014b. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR)
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2013. CMS-1599-p, Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and proposed fiscal year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; Medicare program; proposed rule (vol.
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2015. Medicare's hospital readmissions reduction program in surgery may disproportionately affect minority-serving hospitals.
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