Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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Some have proposed accounting for social risk factors in uality q measurement and payment as a way to address the negative consequences of the status quo. Accounting for social risk factors extends the logic of clinical risk adjustment, which accounts for underlying clinical risk factors that can independently drive variation in performance and may differ systematically across providers, and which can therefore statistically bias measured performance, to also include social risk factors.
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Accounting for social risk factors can achieve important policy goals. It can align incentives to reduce disparities and improve quality and efficiency both for socially at-risk populations and overall.
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. B Although VBP programs have catalyzed health care providers and plans to address social risk factors in health care delivery through their focus on improving health care outcomes and controlling costs, the role of social risk factors in producing health care outcomes is not generally reflected in payment under current VBP design.
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In the second report, the committee reviewed the performance of providers disproportionately serving socially at-risk populations, discussed drivers of variations in performance, and identified six community-informed and patient-centered systems practices that show promise to improve care for socially at-risk populations. The committee's third report identified social risk factors that could be considered for inclusion in Medicare quality measurement and payment, criteria to identify these factors, and methods to account for them in ways that can promote health equity and improve care for all patients.
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As presented in its third report (NASEM, 2016b) , the committee's four goals in accounting for social risk factors in Medicare payment programs are 1.
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Whether a social risk factor is modifiable or unmodifiable is not binary, but rather describes a spectrum of effects. Thus, it can be challenging to identify where a given social risk factor lies on this spectrum, particularly as health care providers and plans are increasingly addressing social risk factors for poor health outcomes.
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Such data collection will also facilitate monitoring for potential unintended consequences of accounting for social risk factors in VBP on health disparities.2 Data from providers and plans include electronic health record (EHR) data and administrative data that providers and plans send to CMS.
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For the indicators listed in bullets under each social risk factor, bold lettering denotes measurable indicators that could be accounted for in Medicare VBP programs in the short term; italicized lettering denotes measurable indicators that capture the basic underlying constructs and currently present practical challenges, but are worth attention for potential inclusion in accounting methods in Medicare VBP programs in the longer term; and plain lettering denotes indicators that have considerable limitations. a As described in Figure 1-1, health care use captures measures of utilization and clinical processes of care; health care outcomes capture measures of patient safety, patient experience, and health outcomes; and resource use captures cost measures.
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The committee recommended that, as such evidence emerges, CMS should revisit inclusion of these indicators in Medicare quality measurement and payment programs. In addition to the five domains of social risk factors, the committee also considered the influence of health literacy on performance indicators 3 See Recommendation 7 in the committee's fourth report (NASEM, 2016c)
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TABLE S-1 Summary of Data Availability for Social Risk Factor Indicators 11
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Additionally, clinical risk factors included in existing Medicare VBP clinical risk adjustments capture clinical elements of disability through major clinical diagnoses. Accounting for social risk factors could capture additional risk unmeasured by clinical risk factors not currently accounted for in Medicare payment programs.
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Just as overall performance can lead to quality improvement for all beneficiaries, publicly reported performance scores stratified by social risk factors could influence beneficiaries' choices by allowing patients to see which providers or plans provide the best care for patients like them. Because public reporting with stratification by patient characteristics within reporting units is the only method that presents information on subpopulations and can therefore highlight any disparities that may exist, it is also the only method 5 See Conclusion 7 in the committee's third report (NASEM, 2016b)
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The current system generally does not take these factors into account. Because social risk factors should no longer have substantial influence on performance measure scores, accurate adjustment would reduce incentives to avoid patients with social risk factors.
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Because directly adjusting payments does not affect publicly reported measures, this method does not make disparities visible unless coupled with public reporting stratified by patient characteristics within reporting units. Relatedly, if payment is directly adjusted, but performance is still reported without adjustment, then there could be incentives to avoid patients with social risk factors.
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Conclusion: The committee supports four goals of accounting for social risk factors in Medicare payment programs: reducing disparities in access, quality and outcomes; improving quality and efficient care delivery for all patients; fair and accurate reporting; and compensating health plans and providers fairly. These goals would best be achieved through payment based on performance measure scores adjusted for social risk factors (or adjusting pay ment directly for these risk factors)
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MOVING FORWARD The committee recognizes that implementing any approach to accounting for social risk factors in Medicare quality measurement and payment can be complex and will require substantial analyses to identify the best approaches to do so for different Medicare incentive programs; it will also require considerable resources -- including costs. This final report provides some clarifications, observations, and other considerations to guide ASPE and CMS if they choose to begin accounting for social risk factors in Medicare payment programs, and to help them to identify priorities and preferences from among the options presented.
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Improving Care for All Socially At-Risk Populations To the extent that accounting for social risk factors in Medicare payment improves fairness in compensating providers disproportionately serving socially at-risk populations, doing so may increase the resources available to these providers to invest in quality improvement and disparities reduction. The approaches the committee identified to account for social risk factors in quality measurement and payment could be applied to other payers, which could further increase resources to these providers via the same mechanisms as under Medicare.
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In the case of accounting for social risk factors, changes to the current VBP system would especially influence the lives of patients with social risk factors who have historically experienced barriers to accessing high quality health care. Together, accounting for social risk factors in quality measurement and payment in combination with complementary approaches may achieve the policy goals of reducing disparities in access, quality, and outcomes, as
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2014. Quality measures and sociodemographic risk factors: To adjust or not to adjust.
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2016a. Accounting for social risk factors in Medicare payment: Identifying social risk factors.
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2004. Paying for quality: Providers' incentives for quality improvement.
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