Accounting for Social Risk Factors in Medicare Payment Identifying Social Risk Factors (2016) / Chapter Skim
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and other social risk factors could be accounted for in Medicare payment and quality programs. The IOM convened an ad hoc committee to conduct a series of five reports related to this task, of which this is the first report.
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2 POTENTIAL UNINTENDED CONSEQUENCES OF VALUE-BASED PAYMENT ON VULNERABLE POPULATIONS AND HEALTH DISPARITIES Improving Value-Based Payment to Address Unintended Consequences While the impact of VBP 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 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 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. In its June 2013 Report to the Congress, the Medicare Payment Advisory Commission (MedPAC)
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Although an independent risk factor and not a social factor, the committee included health literacy as another important factor. 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 have 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.
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Additionally, Medicare coverage and the measures used to assess health care quality and outcomes do not differ for Medicare beneficiaries by origin of entitlement, except for certain measures of ESRD care and outcomes, and thus the health outcomes in the framework are also equally applicable. Current Medicare quality measures fall within each of the domains embraced by the committee in the expanded definition of "health outcomes." Table S-1 contains examples of Medicare quality measures currently in use in each of the health care use and outcome domains embraced by the committee in the expanded definition of "health outcomes." COMMITTEE PROCESS AND OVERVIEW OF THIS REPORT The committee comprises expertise in health disparities, social determinants of health, risk adjustment, Medicare programs, health care quality, health system administration, clinical medicine, and health services research.
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6 ACCOUNTIN FOR SOCIA RISK FACTO IN MEDIC NG AL ORS CARE PAYMEN NT F FIGURE S-1 Conceptual framew of social ris factors for heal care use, outco C work sk lth omes, and cost. N NOTE: This conc ceptual framewor illustrates prim rk mary hypothesized conceptual relat d tionships.
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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 • 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 committee identified literature indicating that occupation may influence health care utilization, health outcomes, and patient experience. • The committee identified no literature indicating that socioeconomic position may influence patient safety outcomes.
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Although race and ethnicity reflect many different social circumstances, there can also be important heterogeneity in health within race and ethnic groups, driven for example by SEP heterogeneity or heterogeneity in English language proficiency, country of origin, time in the United States, or other cultural dimensions. The committee made the following findings: • The committee identified literature indicating that race and ethnicity may influence health care utilization, clinical processes of care, costs, health outcomes, patient safety, and patient experience.
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The committee made the following findings: • The committee identified literature indicating that marital status may influence health care utilization, clinical processes of care, costs, health outcomes, and patient experience. • The committee identified literature indicating that social support may influence heath care utilization, clinical processes of care, health outcomes, and patient experience.
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. The committee made the following finding: • The committee identified literature indicating that health literacy may influence health care utilization, clinical processes of care, cost, and patient experience.
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2015. Accounting for socioeconomic status in medicare payment programs: ASPE's work under the IMPACT Act.
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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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