Accounting for Social Risk Factors in Medicare Payment Criteria, Factors, and Methods (2016) / Chapter Skim
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4 Methods to Account for Social Risk Factors in Medicare Value-Based Payment
4 Methods to Account for Social Risk Factors in Medicare Value-Based Payment
Pages 74-103
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From page 74... ...
to account for social risk factors will require weighing these potential harms. Given that the Medicare payment landscape is evolving and the Centers for Medicare & Medicaid Services (CMS)
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. Additionally, although not considered entirely VBP models nor do they classify strictly as financial incentives or APMs, Medicare Advantage and Part D have design features that tie quality and cost performance to payment, and thus are relevant for purposes of accounting for social risk factors in payment.
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Current Alternative Payment Models APM with Downside Risk: End-Stage Renal Disease Quality Improvement Program The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 authorized the End Stage Renal Disease (ESRD)
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Other Current Value-Based Payment Models and Mechanisms Medicare Advantage/Part C Bonus Payments Medicare Advantage is the insurance program that covers Part A (inpatient care) and Part B (outpatient care)
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. Skilled Nursing Facility Value-Based Purchasing The Protecting Access to Medicare Act of 2014 authorizes a skilled nursing facility incentive program and also specifies details about quality measures, scoring performance, the performance standards and periods, and public reporting (CMS, n.d.-c)
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Three such payment models that tie payment to quality and efficiency of care delivered to Medicare beneficiaries, and thus for which accounting for social risk factors may be relevant, are described below. Bundled Payment Care Improvement The Bundled Payments for Care Improvement (BPCI)
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. POTENTIAL HARMS OF THE STATUS QUO COMPARED TO ACCOUNTING FOR SOCIAL RISK FACTORS Although adjustment for social risk factors could have important benefits, any proposal to account for social risk factors in Medicare payment programs will entail its own advantages and disadvantages that need to be carefully considered.
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From page 81... ...
For example, as described in the previous section, Medicare Advantage plans receive a risk-adjusted annual capitated rate and receive bonuses for achieving quality benchmarks based on performance measures risk adjusted for clinical, behavioral, and some social risk factors under the Five-Star Quality Rating System. However, even after adjustment, plans that have a large number of individuals with social risk factors find it more difficult to achieve the benchmarks because these individuals have lower adherence and greater difficulty managing illnesses, making it difficult for the insurer to obtain star ratings comparable to other plans (Young et al., 2014)
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Finally, some methods of accounting for social risk factors could obscure differences due to poor quality care, such as failure to tailor care or provide culturally competent care, which may result in uneven relative allocation of rewards relative to effort. Conclusion 4: It is possible to improve on the status quo with regard to the effect of value-based payment on patients with social risk factors.
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From page 83... ...
. Thus, the committee's review of methods to account for social risk factors in Medicare VBP programs takes as the point of departure that the goal of Medicare payment and reporting systems are reducing disparities in health care access, affordability, quality, and outcomes; quality improvement and efficient care delivery for all patients; fair and accurate public reporting; and compensating providers for the services they provide.
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restructuring payment incentive design -- encompassing ten methods to account for social risk factors in that could be used to address policy goals of reducing disparities in access, quality, and outcomes; quality improvement and efficient care delivery for all patients; fair and accurate public reporting; and compensating providers fairly. Public reporting seeks to make overall quality visible -- to consumers, providers, payers, and regulators (IOM, 2007)
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risk adjustment in the payment formula without adjusting measured performance (i.e., applying a different payment threshold or increment for rewards or sanctions based on the reporting unit's mix of social risk factors)
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86 ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT them in more detail along with prerequisites or optimal conditions for implementation, as well as potential advantages and disadvantages. Because considerations for cost performance may differ compared to quality performance, the table also notes special concerns for cost-related incentive programs, including bundled and global payment.
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Likewise, Requires sufficient other characteristics of sample sizes. patients with more social risk factors such as low educational attainment, may cause under-use of services relative to need.
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Any effects on payment are indirect and one must consider the particular form of the payment function. 1.Risk Statistical Social risk factors can Scores improve with Effects on payment may be Adjustment will adjustment for methods are used be measured at the improvement in care to any limited.
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From page 89... ...
by patient characteristics. May reduce disincentives to avoid patients with social Does not make disparities risk factors compared to no visible without also using adjustment.
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with at-risk without based on mix of Providers/health plans can be populations through adjusting social risk factors Social risk factors Improvement in care for at- rewarded despite poor bundled, global or measured -- specifically result in differential risk populations is outcomes/performance. shared savings performancef increase the ROI cost of improvement differentially rewarded.
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D Restructure Payment Incentive Design Measures of Social Risk Factors Not Explicitly Used but Implicitly Accounted For g Damberg et al., 2015.
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. The committee lists this approach here to acknowledge the benefits and risks of such an approach vis à vis accounting for social risk factors in other Medicare payment systems.
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measures -- like inpatient safety measures – can be expected to have little relationship to social risk factors. Ideally, the measures not affected by social risk factors signal high quality/value overall.
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94 Special Prerequisites/Optimal Considerations for Method Description Conditions Potential Advantages Potential Disadvantages Cost 3. Add bonus In addition to Adequate sample sizes Directly rewards equity.
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TABLE 4-2 Potential Harms of Accounting for Social Risk Factors Compared to the Status Quo Status Quo Accounting for Social Risk Factors Patient dumping/avoidance Reduces this risk relative to the status quo Unfair to providers disproportionately serving Unfair to providers who provide high quality care to socially at-risk populations (if factors beyond all patients if truly poor quality causes poorer provider control -- and/or the cost of improvement is performance for socially at-risk patients higher for populations with social risk factors -- causes poor performance) Will reduce quality and access for socially at-risk Reduces this risk relative to the status quo populations Incentives to improve care might favor focusing on Same unless payment is adjusted upward for socially patients with few social risk factors if they are easier at-risk populations to improve BOX 4-1 Example: Stratification by Social Risk Factors and Simple Adjustment of a Quality Measure to Reflect Varying Levels of Social Risk Factors Across Providers This example shows the calculation of a hypothetical adjusted quality measure.
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From page 96... ...
TABLE 1 Patient Mix Across Providers High Level of Lower Social Risk Level of Social Total Factors Risk Factors Patients % High-Risk Provider A 20 80 100 20.0% Provider B 40 60 100 40.0% Provider C 80 20 100 80.0% "National" 140 160 300 46.7% Table 2 presents the unadjusted overall score for each provider and nationally, as well as scores stratified by patients' level of social risk. Here, each provider performs better for the lower social risk group than for the disadvantaged group with more social risk factors.
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From page 97... ...
In the current world in which such scores are adjusted in some instances for clinical risk factors, but not social risk factors, all of these providers have incentives to limit their service to patients at high social risk. In addition, those with above average share of high risk patients are financially penalized for the poorer process or outcomes measures which may perpetuate a perverse cycle of under-reimbursement for patients that might require extra resources to treat.
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From page 98... ...
MONITORING METHODS TO ACCOUNT FOR SOCIAL RISK FACTORS As described earlier in the chapter, accounting for social risk factors in Medicare valuebased purchasing programs is intended to achieve a balance between incentives for reducing disparities in access, quality, and outcomes; quality improvement and efficient care delivery for all patients; fair and accurate public reporting; and compensating providers fairly. Both the status quo and any new approach to accounting for social risk factors will have uncertain trade-offs in terms of these goals -- many unknowable factors including provider and patient beliefs and behavioral responses will affect the results that any new system yields.
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2014a. End-stage renal disease quality incentive program payment year 2016 program details.
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n.d.-c. The skilled nursing facility value-based purchasing program (SNFVBP)
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2014. 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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. MedPAC (Medicare Payment Advisory Commission)
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From page 103... ...
2016a. Accounting for social risk factors in medicare payment: Identifying social risk factors.
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