Accounting for Social Risk Factors in Medicare Payment Data (2016) / Chapter Skim
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3 Data Sources and Data Collection for Social Risk Factors
3 Data Sources and Data Collection for Social Risk Factors
Pages 35-66
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From page 35... ...
, the committee expanded the framework to include specific indicators, or ways to measure, the social risk factors. The committee also developed five criteria for selecting social risk factors that could be accounted for in Medicare quality measurement and payment programs and applied them to the social risk factor indicators.
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From page 36... ...
The recommendations in this report indicate things CMS should do if it decides to move toward accounting for social risk factors. To assess the advantages and disadvantages of specific data sources for specific social risk factor indicators, the committee identified three characteristics to consider: (1)
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From page 37... ...
The committee notes that its focus is on social risk factors important for use in Medicare quality measurement and payment. The EHR will include information on social and behavioral risk factors important to the clinical encounter but that would not be relevant for application to Medicare performance measurement and payment.
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From page 38... ...
DATA SOURCES FOR SOCIAL RISK FACTORS Recommendation 2: The committee recommends that the Centers for Medicare & Medicaid Services use existing data on dual eligibility, nativity, and urbanicity/rurality in Medicare performance measurement and payment. Dual Eligibility For the Medicare population, Medicaid eligibility -- also referred to as dual (Medicare and Medicaid)
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From page 39... ...
For the purpose of inclusion in Medicare performance measurement and payment, urbanicity/rurality of a beneficiary's place of residence is likely to be a more salient indicator of his or her social risk factors. Although urbanicity/rurality is conceptually continuous, it can be measured dichotomously (i.e., urban or rural)
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From page 40... ...
. Race and ethnicity also have clinical utility social risk factors and were included in the 2014 IOM report on capturing social and behavioral domains and measures.
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From page 41... ...
If so, validated measures of partnership exist in the literature, but CMS would need to develop standardized measures and data collection methods for its own collection or provider/plan reporting requirements. An important consideration for the longer term are ongoing demographic shifts in family structure, including the decline in marriage rates and increases in cohabiting individuals and persons who never marry (Aughinbaugh et al., 2013; Liu and Umberson, 2008; Tamborini, 2007; Wang and Parker, 2014)
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From page 42... ...
In the long term, research is needed on measurement and data collection for partnership. In particular, CMS may want to examine whether including partnership in any method to account for social risk factors in Medicare quality measurement and/or payment that already includes marital status and living alone adds substantial additional precision and explanatory value.
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From page 43... ...
In the longer term, CMS should explore the feasibility of linking to SSA income data from the uncapped Medicare payroll tax and/or develop standardized measurements and methods for new data collection. Education Education can affect health and health care outcomes directly by enabling individuals to access and understand health information and health care, to make decisions that promote health and reduce health risks, and to advocate for him- or herself in health care (Cutler and LlerasMuney, 2006; IOM, 2014)
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From page 44... ...
, most counties are likely to be too heterogeneous for county-level measures of neighborhood deprivation to be useful. To be meaningful for certain methods of accounting for social risk factors in Medicare quality measurement and payment, the geographic area should have sufficient variability with respect to provider and plan performance.
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From page 45... ...
, and therefore are useful for examining the effect of wealth on health care outcomes. However, as described in Chapter 2, because samples for the HRS are small, these data are unlikely to be useful for application in Medicare quality measurement or payment.
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From page 46... ...
As described in Chapter 2, national surveys such as the HRS that can be linked to individual-level health care outcomes of Medicare beneficiaries could serve as a test bed for CMS to assess this question. Living Alone Living alone is a structural element of social relationships, which is typically an indicator of social isolation or loneliness in health research, and which is also likely to capture elements of social support (Berkman and Glass, 2000; Brummett et al., 2001; Cohen, 2004; Eng et al., 2002)
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From page 47... ...
Recommendation 6: The committee recommends that research be conducted on the effect of acculturation, sexual orientation and gender identity, and environmental measures of residential and community context on health care outcomes of Medicare beneficiaries and on methods to accurately collect relevant data in the Medicare population.
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From page 48... ...
Thus, normative gender is a strong candidate for inclusion in methods to account for social risk factors in Medicare quality measurement and payment programs. However, the committee notes that gender is already included as a risk factor in clinical risk adjustments in Medicare.
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From page 49... ...
Recommendation 7: The committee recommends that the Centers for Medicare & Medicaid Services collect information about relevant, relatively stable social risk factors, such as race and ethnicity, language, and at the time of enrollment. Indicators for which data might best be captured through a revised enrollment form include race and ethnicity, language, and education.
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From page 50... ...
home) Could have clinical utility Using documentation status rather than country of origin is sensitive; a potential cost of using documentation status may be the burden of handling information on undocumented persons on CMS, providers, and plans Urbanicity/ Based on residential Based on residential Area-level measures Use available area-level Rurality address, which is in address, which is at census tract level measure at census tract the Medicare record currently collected in from the American level from the ACS.
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From page 51... ...
2. Data sources with some limitations exist that could be used in the short term, and CMS should conduct research on new or improved data collection strategies in the long term.
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From page 52... ...
52 ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT: DATA Social Risk Existing or New Alternative Factor Sources of CMS Data Sources from Government Data Proposed Data Indicator Data Providers and Plans Sources Other Considerations Collection Strategy and reporting Current methods exist to impute where direct self report not available; methods also being continually refined Language Available with high Collection of preferred Area-level measure Medicare has a limited Short term: Use specificity, but lower language using from ACS available English proficiency plan, existing CMS data sensitivity Library of Congress which requires providing despite their limitations language codes Imputation methods language-appropriate included in Stage 2 available for some materials to beneficiaries EHR meaningful use languages who ask for materials in Long term: CMS should regulation languages other than English, collect at the time of but currently includes no enrollment and Health plans have proactive data collection standardize collection good data, and if across different methods standardized, could (EHRs and submit to CMS administratively) Marital/ Marital status part of Partnership data could No other existing Data sources and data needs Short term: Use marital partnership the Medicare record be collected because it sources of partnership for marital status and status data that Medicare status (collected and can change over time status partnership status may need already has maintained because and has clinical utility, to be considered separately they are important but would require Long term: Partnership for Social Security standardized data Need to consider potential could be collected benefits)
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From page 53... ...
Area-level measures could be used in the short term, but CMS should research standardized measurement and data collection for the long term Income No existing data; Possible, but may be Individual-level data SSI is also available, but Short term: Use area need further research burdensome to collect from the SSA represents only part of total level ACS measure as an on standardized data (lifetime earnings, income for more affluent imperfect proxy collection Potential accuracy Medicare payroll tax, beneficiaries, but may be a issues Supplemental large part for less Long term: Assess Security Income advantaged beneficiaries possibility of linking to May not be clinically [SSI]
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From page 54... ...
composite has better should construct measurement properties alternative measures and see how they perform Need to identify geographic when included in areas that both meaningfully methods to account for capture the neighborhood social risk factors in and also have sufficient quality measurement/ variability regarding payment plan/provider performance (possibly census tracts for Long term: Monitor the urban; counties for rural performance of the effect, but few rural studies) selected measure across rural and urban areas Most existing neighborhood deprivation indices are To improve accuracy, designed to apply to and are CMS could conduct tested for use in urban areas; additional research to conceptually, what identify the appropriate constitutes "deprivation" in a geographic area to rural setting may differ capture the "neighborhood" effect Thus, traditional indicators that applies to rural included in neighborhood settings deprivation indices may not CMS could also conduct
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From page 55... ...
) , but no May not be clinically requirement and good measure for EHRs useful because would be partly or collection by CMS providers can address captured through dual but not intervene eligibility status Long term: More research is needed on whether wealth adds additional precision/discrimination above and beyond income to warrant inclusion of wealth as well Living alone Some limited data Could be collected Area data from the May change rapidly among Long term: Develop exist for because it can change ACS may be useful Medicare beneficiaries; measures and methods beneficiaries in over time, especially for certain geographic therefore, it may best be for collection through for older adults, and regions with collected periodically in the
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From page 56... ...
) Social No existing data Could be collected No existing data May change rapidly among Long term: Develop support because it can change sources Medicare beneficiaries; measures and methods over time, especially therefore, it may best be for collection through for older adults, and collected periodically in the EHRs has clinical utility, but clinical context would require further research on standardized data collection Some measures exist in the literature that could be used Housing No existing data Could be collected Area-level measures Short-term: CMS should stability and because it can change of housing quality test area-level measures quality over time and has (e.g., type, age, and compare their clinical utility, but amenities and utilities performance would require further available, cost/value, research on taxes)
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From page 57... ...
4. Some measures exist, but more research is needed on the effect of the social risk factor indicator on health care outcomes of Medicare beneficiary and on methods to accurately collect data for the Medicare population Accultura- No existing data; Could be accurately No existing data Validated measures are Long term: Needs more tion need further research collected with little sources available in the literature research on the effect of on standardized data burden, but is not acculturation on collection currently collected performance indicators used in value-based Language use could Could have clinical payment (VBP)
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From page 58... ...
is the research on the effect of Gender general interest and data collection included in some relevant construct to assess sexual orientation and identity throughout the methods are needed national surveys (e.g., gender identity on health Department of National Health care outcomes of interest Health and Human Interview Survey and standardized Services to collect [NHIS] , National measurement.
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From page 59... ...
DATA SOURCES AND DATA COLLECTION FOR SOCIAL RISK FACTORS 59 Social Risk Existing or New Alternative Factor Sources of CMS Data Sources from Government Data Proposed Data Indicator Data Providers and Plans Sources Other Considerations Collection Strategy Other No existing data No existing data Area-level measure, Examples of indicators Long term: Needs further environ- needs to be thought include transportation research on the effect on mental about much more as availability and exposure to health care outcomes of measures evidence develops; environmental hazards interest need to wait for more evidence of Could be revisited when association with more evidence is health care outcomes available, but of interest and standardized data indicators used in collection is needed VBP
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From page 60... ...
ple, usting health pla quality measures may require dat from diffe an m y ta erent sources compared t risk adjusting s to hospital quality meas q sures, becaus for exam se, mple, social ri factors th affect the outcome or isk hat e cost of a hospitalizati likely differ from tho that affe quality or total cost of care measu ion ose ect r ures. Similarly CMS may need data on social risk factors rega y, o k ardless of whhether care i sought or not is when acc counting for social risk factors in hea plan or a f alth accountable care organizzation performa ance scores; whereas, for adjustment related to p r t performance measures th are associ hat iated with a heealth care episode, it may make sense to have pro y oviders repo Thus, any indicator m ort.
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From page 61... ...
Conclusion 2: Different data collection strategies for the same social risk factor indicator may be warranted depending on the purpose or methods used to account for social risk factors in Medicare performance measurement and payment. Additionally, the advantages and disadvantages of any specific source should be considered in reference to the intended use.
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From page 62... ...
2013. Behavioral Risk Factor Surveillance System questionnaire.
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From page 63... ...
2015. Imputing missing race/ethnicity in pediatric electronic health records: Reducing bias with use of U.S.
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From page 64... ...
2016a. Accounting for social risk factors in Medicare payment: Identifying social risk factors.
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From page 65... ...
2012. The validity of race and ethnicity in enrollment data for Medicare beneficiaries.
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