Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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Pages 315-334
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From page 315... ...
. Stakeholders have raised concerns that current Medicare quality measurement and payment programs, and VBP programs in particular, that do not account for social risk factors may underestimate the quality of care provided by providers disproportionately serving socially at-risk populations.1 Patients with social risk factors may require more resources and more intensive care to achieve certain health outcomes compared to the 1 Note, the term provider in this report refers to the reporting unit (or, provider setting)
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In the first report, the committee presented a conceptual framework and described the results of a literature search linking five social risk factors and health literacy to healthrelated measures of importance to Medicare quality measurement and payment programs -- referred to in this report as performance indicators used in VBP. In the second report, the committee reviewed the performance of pro iders disproportionately serving socially at-risk populations, discussed v 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.
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This report builds on the conceptual relationships and empirical asso ciations between social risk factors and performance indicators used in VBP identified in the first report to provide guidance on which factors could be considered for Medicare accounting purposes, criteria to identify these factors, and methods to do so in ways that can improve care and promote greater health equity for socially at-risk patients. To that end, the committee also aims to address issues that must be carefully considered to maintain or enhance provider incentives to improve care for socially at-risk patients throughout the report while also promoting accuracy in reporting and compensating providers fairly.
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Criteria developed to select risk factors for prior risk adjustment models that the committee reviewed and drew upon in developing their criteria are listed in Appendix CA. Conclusion 1: Three overarching considerations encompassing five cri teria 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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In the medical field, insurance status is also used as a proxy for SEP. Income and education are promising indicators of SEP, because they are related to health care outcomes of interest, precede care delivery and are not a consequence of the quality of care, and meet practical considerations; measures are likely to be resistant to gaming and manipulation.
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This category is the most basic pair of criteria for a social risk factor -- that there be both a plausible and valid reason why the risk factor would be associated with the outcome and empirical evidence that such a relationship holds in practice. Together these criteria lay the foundation for the validity and practical importance of the risk factor.
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Carefully monitor high-leverage factors (i.e., risk factors that are not prevalent but highly predictive of outcomes) , as they may be important but especially attractive for gaming.
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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 the conceptual framework outlining primary hypothesized conceptual relationships between social risk factors and outcomes used in VBP presented in the committee's first report (NASEM, 2016a)
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. Compositional characteristics and environmental measures of residential and community context are related to health care outcomes, precede care delivery and are not a consequence of the quality of care, are not modifiable through provider action, and generally meet practical considerations, with some limitations.
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Never theless, it may be desirable to otherwise compensate providers for the greater effort or costs required to provide health literate care and thereby produce good health care outcomes. After applying the selection criteria to indicators of the five social risk factors and health literacy, the committee made the following conclusions: 2 The committee sees no conflict between this report and the 2013 IOM report Variation in Health Care Spending: Target Decision Making, Not Geography, which recommended against using area-level payment adjustments to account for regional practice patterns.
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Conclusion 3: There are some indicators of social risk factors that capture the basic underlying constructs and currently present practi cal challenges, but they are worth attention for potential inclusion in accountng methods in Medicare value-based payment programs in the i longer term. These include • Wealth, • Acculturation, • Gender identity and sexual orientation, • Emotional and instrumental social support, and • Environmental measures of residential and community context.
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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. The status quo (which does not account for social risk factors)
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Methods to Account for Social Risk Factors The committee's review of methods to account for social risk factors in Medicare VBP programs takes as the point of departure that the goals 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 fairly for the services they provide. Differences in quality by populations with social risk factors may reflect a combination of drivers, including mechanisms that occur during the patient–provider encounter (e.g., discrimination, bias)
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From page 329... ...
direct adjustment of payments; and (D) restructuring payment incentive esign -- ncompassing 10 methods to account for social risk factors d e 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.
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Direct adjustments of payment explicitly use measures of social risk factors, but by themselves do not affect performance measure scores. Methods include (1)
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Conclusion 7: Strategies to account for social risk factors for measures of cost and efficiency may differ from strategies for quality measure ment, because observed lower resource use may reflect unmet need rather than the absence of waste, and thus lower cost is not always better, while higher quality is always better. Monitoring Both the status quo and any new approach to accounting for social risk factors will have uncertain tradeoffs in terms of the goals of reducing disparities in access, quality, and outcomes; quality improvement and efficient care delivery for all patients; fair and accurate public reporting; and com
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Conclusion 8: Any specific approach to accounting for social risk fac tors in Medicare quality and payment programs requires continuous monitoring with respect to the 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. Finally, because behavioral and other responses to new systems may change the balance of risks and benefits over time, to take into account these behavioral and other responses, the specific approach to accounting for social risk factors may need to be reassessed.
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2016a. Accounting for social risk factors in Medicare payment: Identifying social risk factors.
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