Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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A1: Introduction
A1: Introduction
Pages 125-158
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. Specific payment strategies include pay-for-performance and other quality incentive programs that tie financial rewards and sanctions to the quality and efficiency of care provided, and risk-based alternative payment models (APMs)
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citizens or permanent legal residents. Medicare consists of four programs: • Part A, the hospital insurance program that pays fee-for-service for inpatient hospital care, skilled nursing facility care, hospice care, and home health care; • Part B, the medical insurance program that pays fee-for-service for outpatient care (physician services)
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Reauthorization Act of 2015 require CMS to implement VBP programs for Medicare inpatient hospital care, ambulatory care, health plans, and post-acute care. Currently, there are eight VBP programs in Medicare, with two post-acute care programs in proposal or planning.3 These programs are summarized below and in Table A1-1.
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program; 1% in 2013, increasing Patient experience (taken from the 0.25% each year until 2% Hospital Consumer Assessment of Healthcare Providers and Suppliers Survey) Clinical outcomes (30-day mortality for AMI, HF, and PN, as well as certain patient safety measures from AHRQ PSI 90 Composite and CDC NHSN CLABSI)
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of less than 0.5%; only 8 percent comorbidities of hospitals received bonuses of 0.5% or greater, and 18 percent of hospitals received penalties of 0.5% or greater.j Patient experience: education, self-rated health, response percentile, primary language other than English, age, service line (maternity/surgical/ medical) , interactions (surgical line*
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met minimum reporting requirements) : fixed negative adjustment of –1% in 2015 and –2% in 2016 End-Stage –2% Quality: clinical measures (anemia Renal Disease management, dialysis adequacy, iron Quality Incentive management, bone mineral metabolism, Programr vascular access, patient satisfaction)
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Among these, 14 groups received status, mental health status, upward adjustments for performance, 81 received no Medicaid status, low-income adjustments, 11 received negative adjustments, and subsidy, Asian language survey 21 received no adjustment due to insufficient data to (Cantonese/Korean/Mandarin/ determine quality and cost performance. A total of $11.4 Vietnamese)
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y 20% of the costs that are higher than expected Skilled Nursing –2% if facilities do not For 2018, quality domains include skin Facility report quality data on three integrity and changes in skin integrity; Value-Based domains incidence of major falls; functional Purchasingaa status, cognitive function, and changes Incentive program begins in function or cognitive function. in 2019 CMS proposed the NQF-endorsed, 30 day all-cause readmission measures for the incentive program Home Health Incremental increase in Proposed measures to cover clinical Value-Based maximum penalties or processes, clinical outcomes, patient Purchasingbb rewards of 5% in 2018, safety, patient and caregiver experience, 6% in 2020, 8% in 2021 population/community health, efficiency, and cost reduction NOTE: ACO = accountable care organization; AHRQ = Agency for Healthcare Research and Quality; AMI = acute myocardial infarction; CDC = Centers for Disease Control and Prevention; CMS = Centers for Medicare & Medicaid Services; CLABSI = Central Line-asso iated c Bloodstream Infection; COPD = chronic obstructive pulmonary disease; FY = fiscal year; HCC = hierarchical condition categories; HF = heart failure; MSSP = Medicare Shared Savings Program; NHSN = National Healthcare Safety Network; NQF = National Quality Forum; PN = pneumonia; PSI = patient safety indicator.
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b Unless indicated otherwise, the information in this row is from CMS, 2014d. c Boccuti and Casillas, 2015.
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bb Unless indicated otherwise, information in this row is from HHS, 2015. Medicare Value-Based Payment Programs for Hospital Inpatient Care Hospital Readmissions Reduction Program The Hospital Readmissions Reduction Program (HRRP)
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. Medicare Value-Based Payment Programs for Ambulatory Care Medicare Shared Savings Program The Medicare Shared Savings Program (MSSP)
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At the end of each performance period, CMS compares MSSP ACOs' actual spending to the calculated benchmark. As of January 1, 2015, 404 ACOs covering 7.92 million Medicare beneficiaries in 49 states; Washington, DC; and Puerto Rico entered into a Shared Savings Program agreement with CMS (CMS, 2015d)
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. Medicare Value-Based Payment Programs for Health Plans4 Medicare Advantage/Part C As described in the previous section, MA or Medicare Part C is the insurance program that covers the Part A and Part B benefits, typically offers Part D prescription drug coverage, and may offer additional benefits and services at additional cost (MedPAC, 2015b)
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Medicare Value-Based Payment Programs for Post-Acute Care Skilled Nursing Facility Value-Based Purchasing The IMPACT Act requires CMS to implement a quality-reporting program for Skilled Nursing Facilities (SNFs) and the Protecting Access to Medicare Act of 2014 authorizes an SNF incentive program (CMS, 2015j)
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However, based on early results, policy makers, health care researchers, advocates, and other stakeholders have begun to raise concerns about potential unintended consequences VBP may have on health disparities. POTENTIAL UNINTENDED CONSEQUENCES OF VALUE-BASED PAYMENT ON VULNERABLE POPULATIONS AND HEALTH DISPARITIES Impact of Value-Based Payment on Providers Serving Vulnerable Populations A wide range of stakeholders representing government, academia, providers, advocates, and others have raised concerns that some of Medicare's VBP programs, especially the HRRP, may be disproportionately penalizing hospitals serving the most vulnerable patients.
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. Several studies have shown that larger hospitals, teaching hospitals, and safety-net hospitals, which traditionally serve more disadvantaged patients, are more likely to rank poorly on quality measures and therefore are more likely to be penalized under Medicare VBP programs (Berenson and Shih, 2012; Gilman et al., 2014, 2015; Joynt and Jha, 2013; Rajaram et al., 2015)
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Improving Value-Based Payment to Address Unintended Consequences While the impact of value-based purchasing strategies on providers serving vulnerable populations and on health disparities continues to be monitored both under Medicare and more widely, and because more VBP programs are being implemented and existing programs are expanding, some methods have been proposed to improve these payment programs to address the potential unintended consequences on vulnerable populations and disparities. Chief among methods proposed to improve VBP to address these unintended consequences is accounting for differences in patient characteristics when measuring quality and calculating payments, sometimes referred to as risk adjustment or payment adjustment.
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In other words, risk adjustment can include social factors for the purposes of measurement accuracy without affecting payment. Similarly, payment adjustment can be done by basing payment on measures that are risk adjusted or through other m ethods, such as directly funding programs to improve the quality of care for disadvantaged patients (Berenson and Shih, 2012)
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Operating under the assumption that social factors do impact health care quality and efficiency outcomes independently of variations in the provision of health care, a small number of analyses have included SES and other social determinants of health in risk adjustment of provider performance profiles to estimate the effect of including social factors in measuring quality, but findings have been mixed. Three studies found that including these social determinants had no impact on risk adjustment models, and thus hospital rankings (Blum et al., 2014; Eapen et al., 2015; Keyhani et al., 2014)
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. Previous Recommendations for Accounting for Social Risk Factors in Medicare Payment Programs In light of this debate, two expert panels have previously examined whether to include social risk factors in risk adjustment for Medicare payment models and offered recommendations.
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Interpreting the Statement of Task The statement of task for this report includes several key words that drove the committee's work. The statement of task refers to identifying "SES factors" that "have been shown" to "impact" "health outcomes" of "Medicare beneficiaries." This project is intended to provide very practical and targeted input to HHS and Congress as they consider whether to adjust Medicare payment programs for social risk factors.
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that could S potentially be used to determine whether an SES factor or other social factor should be accounted for in Medicare quality, resource use, or other measures used in Medicare payment programs. • dentify SES factors or other social factors that could be incorporated into I quality, resource use, or other measures used in Medicare payment programs.
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Although an independent risk factor and not a social factor, the committee included health literacy as another important factor, because it is specifically mentioned in the IMPACT Act and thus is of interest to Congress, and because it is affected by social factors. Additionally, although the statement of task specifies only examining the impact of these social risk factors on "health outcomes," it also specifies that the social risk factors should be targeted "for the purpose of application to quality, resource use, or other measures used for Medicare payment programs." Thus, given the importance that Medicare VBP programs has placed on this broader set of measures and given that Medicare applies these measures when calculating payments, the committee interpreted "health outcomes" as encompassing measures of health care use, health care outcomes, and resource use.
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148 FIGURE A1-1 Conceptual framework of social risk factors for health care use, outcomes, and cost. NOTE: This conceptual framework illustrates primary hypothesized conceptual relationships.
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In the next (and final) chapter of this report, the committee presents the results of a literature search to identify those social risk factors that have been shown to influence health care use, costs, and health care outcomes.
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long-term diabetes complications, lower-extremity amputation for diabetes) • 30-day mortality after hospital discharge for AMI, heart failure, or pneumonia Patient Safety • AHRQ Patient Safety Indicator composite (pressure ulcer, iatrogenic pneumothorax, central venous catheter-related bloodstream infections, postoperative hip fracture, perioperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, postoperative wound dehiscence, accidental puncture or laceration)
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The committee's interpretation of the task for report one was to define SES for the purposes of application to Medicare payment programs and to identify whether there exists literature showing an influence of one or more social risk factors on one or more measures of relevant health care use or outcomes. In its findings, the committee uses the term "influence" to describe an association between a social risk factor and a health care use or outcome measure without implying a causal association.
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2014a. End-Stage Renal Disease Quality Incentive Program payment year 2016 program details.
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2015c. End-Stage Renal Disease Quality Incentive Program frequently asked ques tions.
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2015. Accounting for socioeconomic status in Medicare payment programs: ASPE's work under the IMPACT act.
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2014b. 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 com pensation 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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2013. CMS-1599-p, Medicare program; hospital Inpatient Prospective Payment Systems for acute care hospitals and the long-term care hospital Prospective Payment Sys tem and proposed fiscal year 2014 rates; quality reporting requirements for specific pro viders; hospital conditions of participation; Medicare program; proposed rule (vol.
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