Accounting for Social Risk Factors in Medicare Payment Criteria, Factors, and Methods (2016) / Chapter Skim
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1 Introduction
1 Introduction
Pages 16-21
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From page 16... ...
being evaluated -- e.g., hospitals, health plans, provider groups, etc. A wide range of stakeholders has raised concerns that current Medicare quality measures and payment programs that financially reward or penalize providers based on the health care outcomes of their patients and do not account for social risk factors may underestimate the quality of care for such providers.
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As defined in the committee's first report and discussed in more detail in Chapter 4 of this report, although the committee conceives of risk adjustment and payment adjustment as two separate methods, risk adjustment can become a method of payment adjustment when risk adjusted measures are used as the basis of payment. This proposal extends the rationale for adjusting for differences in clinical risk factors across providers to ensure accurate measurement and fair comparisons by taking into account differences that are beyond the control of individual providers (currently performed for all Medicare quality measures and payment programs)
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contracted with the National Academies of Sciences, Engineering, and Medicine to convene an ad hoc committee to identify criteria for selecting social risk factors, specific social risk factors Medicare could use, and methods of accounting for those factors in Medicare quality measurement and payment applications. The committee comprises expertise in health care quality, clinical medicine, health services research, health disparities, social determinants of health, risk adjustment, and Medicare programs (see Appendix B for biographical sketches)
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This report builds on the conceptual relationships and empirical associations between social risk factors and health literacy and quality measures and health care outcomes identified in the first report to provide guidance on which factors could be considered for Medicare accounting purposes, criteria to identify these factors, and methods to do so in ways that can improve care and promote greater health equity for socially at-risk patients. To that end,
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To achieve these goals, accounting for social risk factors should neither mask low-quality care or health disparities nor reward poor performance. Additionally, inclusion of social risk factors in quality measurement and payment should not disincentivize providers from finding strategies to overcome the influence of social risk factors on health care outcomes.
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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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