Accounting for Social Risk Factors in Medicare Payment Criteria, Factors, and Methods (2016) / Chapter Skim
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2 Criteria for Selecting Social Risk Factors for Application in Medicare Quality Measurement and Payment
2 Criteria for Selecting Social Risk Factors for Application in Medicare Quality Measurement and Payment
Pages 22-38
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From page 22... ...
Underlying the assumption that both public reporting and VBP will motivate improvement is the reasoning that performance measurement and comparisons of provider performance will help identify the drivers of variation, which will in turn inform how subpar performance can be improved. At the same time, meaningful comparisons aim to reflect provider performance with all else equal by minimizing the effect of other factors such as patient characteristics that may affect health care quality or outcomes independently of provider influence (Ash et al., 2013)
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GUIDING PRINCIPLES The committee developed selection criteria for social risk factors to support the methods for accounting for social risk factors in Medicare payment, particularly payment tied to performance indicators. Underlying the committee's approach to accounting for social risk factors is a commitment to achieving health equity.
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As described in Chapter 1 and in the committee's first report, critics of accounting for social risk factors in VBP programs are concerned about the potential to institutionalize a poorer standard of care and to reduce incentives to improve care for socially atrisk populations. Proponents are concerned about incentives for providers to avoid socially atrisk populations, further reducing already limited resources among providers disproportionately serving socially at-risk populations, and, consequently, increasing health disparities.
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. On the one hand, some opponents believe that because observed differences in performance indicators used in VBP could reflect actual differences in health care quality as well as the influence of social risk factors, given that it is not possible to determine whether or to what extent the poorer performance is due to real differences, risk adjustment could obscure real disparities and thereby reduce incentives to improve care and reduce health disparities.
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CRITERIA FOR SELECTING SOCIAL RISK FACTORS Conclusion 1: Three over-arching 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.
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Similarly, it would be problematic if all the social risk factors included in a model were selected because of social norms or political considerations rather than an established conceptual relationship. Another practical issue would be to consider whether and how the construct works in a population of interest.
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. For example, one might consider education as a social risk factor for flu immunization in Medicare health plans.
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predict performance indicators used in VBP within reporting units after considering other retained social risk factors. For example, gender might not vary much across health plans (situation a)
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In addition, adjusting for some modifiable risk factors may discourage some means of quality improvement and disparity reduction. To achieve goals of VBP as stated above, it is critical to consider whether risk factors are the consequence of provider efforts.
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Health care providers can advocate for the inclusion of health in all policies to address underlying social conditions as root causes of health care outcomes, but the responsibility to improve transportation and education systems, reduce poverty, teach English, and ensure a living wage and sufficient affordable housing stock lies outside of the health care system. At the same time, the committee acknowledges that health care providers are increasingly held responsible for addressing social risk factors by, for example, partnering with social service agencies, public health agencies, and community-based organizations.
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Methods of adjusting or otherwise accounting for social risk factors, as described in Chapter 4, can account for unmodifiable risk factors while rewarding providers who provide better, appropriate, tailored care that minimize the impact of social risk factors on certain health care outcomes. The critical challenge of applying this criterion is that it can be difficult to identify the extent to which care provision might affect a particular risk factor in practice.
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Nonetheless, such factors may be particularly important if gaming can be avoided, as a failure to account for such factors could greatly disadvantage providers who care for large proportions of patients with high levels of social risk factors. The committee's criteria along with the rationale and potential challenges of each criterion are summarized in Table 2-1.
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The risk factor If a risk factor present at Does not eliminate a risk factor Prioritize slowly changing factors over rapidly changing is present at the start of care, then it less being a consequence of care delivery variables: Measurement would have to be more start of care likely that it would be the in dynamic settings or under frequent, but rapidly changing variables would not fully result of care provided population health settings disqualify a measure
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Prioritize continuous over dichotomous measures of the same constrict where applicable to reduce "edge" gaming. Carefully monitor high-leverage factors (i.e., risk factors that are not prevalent but highly predictive of outcomes)
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o Monitoring is also necessary to assess whether the use of social risk factors in Medicare payment strategies is appropriately incentivizing both improved quality and reduction in health disparities. Yet the criteria themselves are meant to be stable and reapplied to allow for an adaptive system.
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In Risk adjustment for measuring health care outcomes, edited by L
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2016a. Accounting for social risk factors in medicare payment: Identifying social risk factors.
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