Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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D3: Data Sources and Data Collection for Social Risk Factors
D3: Data Sources and Data Collection for Social Risk Factors
Pages 495-534
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From page 495... ...
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. Based on this activity, the committee concluded that the following indicators could be included in Medicare quality measurement and payment programs in either the short or long term: • income • wealth • education • dual eligibility • race and ethnicity • language • nativity • acculturation 495
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From page 496... ...
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 497... ...
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 498... ...
• Where social risk factors change over time and have clinical utility, requiring data collection through electronic health records or other types of provider reporting may be the best approach. • For social risk factors that reflect a person's context or environ ment, existing data sources that can be used to develop area-level measures should be considered.
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From page 499... ...
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 500... ...
For the purpose of inclusion in Medicare performance measurement and payment, rbanicity/rurality of a beneficiary's place of residence is likely to be a u more salient indicator of his or her social risk factors. Although urbanicity/ rurality is conceptually continuous, it can be measured dichotomously
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From page 501... ...
. Because an area-level measure of urbanicity/rurality is appropriate and a trichotomous classification of census tract-/block-level urbanicity/rurality is available through the Census Bureau, this available measure should be used based on a Medicare beneficiary's residential address in the Medicare record.
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From page 502... ...
. 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 503... ...
and some imputation methods, are also available as individual-level proxies where individual-level data do not exist. Although much research on language and health care outcomes has focused on limited English proficiency rather than preferred language (NASEM, 2016a)
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From page 504... ...
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. As described in Appendix D2, national surveys that can be linked to individual-level health care outcomes of Medicare beneficiaries could serve as a test bed for such an assessment.
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From page 505... ...
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 3 Personal communication, John D
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From page 506... ...
Although some of the more comprehensive EHRs may capture educational attainment, standardized measures and data collection strategies are needed. To that end, the earlier IOM report on social and behavioral domains and measures for EHRs identified education as a clinically useful social risk factor and recommended its inclusion in EHR meaningful use standards.
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From page 507... ...
, 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 508... ...
Wealth Wealth represents total accumulated economic resources (assets) that, like income, can affect health and health care outcomes directly as a means of purchasing health care and indirectly as a means of acquiring health- promoting resources (Braveman et al., 2005; Deaton, 2002; NASEM, 2016a)
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From page 509... ...
Because collecting accurate wealth data is known to be difficult and burdensome and because data collected through EHRs could be done via multiple modes, which could augment potential accuracy issues, EHRs may be less preferable to centralized collection by CMS. In particular, CMS may want to consider the empirical question of whether the addition of wealth data adds sufficient precision above and beyond income data, for which some data are already available and for which methods and measures exist to collect data with less burden to warrant additional data collection for inclusion in any method to account for social risk factors in Medicare quality measurement and payment.
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From page 510... ...
Thus, there are no data sources that could be used in the short term. However, for the long term, because social support can change rapidly especially among older adults and because it has clinical utility, it may best be captured in the clinical setting, and CMS should develop standardized measures and methods for data collection through EHRs.
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From page 511... ...
The committee recommends that CMS research ways to accurately collect housing data, whether at an individual level or an area level. Housing Elements of housing that may influence health and health care outcomes include housing stability, homelessness, and quality and safety.
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From page 512... ...
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 513... ...
In particular, for sexual orientation, CMS should take notice of which dimension or dimensions are most relevant for health care outcomes. At the same time, CMS should continue efforts to develop standardized measures and data collection strategies and to collect data.
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GENERAL CONCLUSIONS In addition to the specific guidance the committee proposed for collecting data for specific social risk factor indicators, the committee also identified several general conclusions for CMS in its overall approach to collecting data on social risk factors for use in Medicare quality measurement and payment. Different data collection strategies for the same indicator may be warranted depending on the purpose or methods it is used for.
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From page 515... ...
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 perfor mance 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 516... ...
Could have clinical utility Urbanicity/ Based on residential Based on residential Area-level measures rurality address, which is in address, which is at census tract level the Medicare record currently collected from the American in Electronic Health Community Survey Records (EHRs)
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From page 517... ...
Preference to use residential address in Medicare record, but with the caveat that there will be some slippage for adjustments to providers in destination areas for people who have more than one primary address (e.g., "snow birds") continued
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From page 518... ...
standards (such as for new enrollees and on sample surveys) , but categories are collapsed in analysis and reporting Current methods exist to impute where direct self report not available; methods also being continually refined Language Available with high Collection of Area-level measure specificity, but lower preferred language from ACS available sensitivity using Library of Congress language Imputation methods codes included available for some in Stage 2 EHR languages meaningful use regulation Health plans have good data, and if standardized, could submit to CMS
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From page 519... ...
) Medicare has a limited English proficiency Short term: Use existing CMS data despite its plan, which requires providing language- limitations appropriate materials to beneficiaries who ask for materials in languages other Long term: CMS should collect at the time than English, but currently includes no of enrollment and standardize collection proactive data collection across different methods (EHRs and administratively)
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From page 520... ...
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 Individual-level need further research be burdensome to data from the SSA on standardized data collect (lifetime earnings, collection Medicare payroll tax, Potential accuracy Supplemental Security issues Income [SSI]
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From page 521... ...
and, correspondingly, changes in the relationship between marital/partnership status and health outcomes SSI is also available, but represents only Short term: Use area-level ACS measure as an part of total income for more affluent imperfect proxy beneficiaries, but may be a large part for less advantaged beneficiaries (and therefore Long term: Assess possibility of linking more useful as a measure of overall income to and using the SSA income data from for them) uncapped Medicare payroll taxes or need research on measurement and data collection Area-level income is an imperfect proxy by CMS for individual-level income, so even if it partly captures an individual-level effect, it can be problematic as an individual-level proxy Short-term: Use ACS areal measure as a proxy Long-term: CMS could conduct research on data collection either by CMS or through EHRs continued
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From page 522... ...
Measures and data collection methods exist, but data sources have considerable limitations and more research is needed to accurately collect data in the long term Wealth No existing data; Burdensome to ask State Medicaid asset needs further threshold data could research on Potential accuracy capture low income, standardized data issues but varies by state collection eligibility requirement May not be and would be partly clinically useful captured through dual because providers eligibility status can address but not intervene
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From page 523... ...
additional research to identify the appropriate geographic area to capture the Most existing neighborhood deprivation "neighborhood" effect that applies to rural indices are designed to apply to and are settings tested for use in urban areas; conceptually, what constitutes "deprivation" in a rural CMS could also conduct research to identify setting may differ salient constructs comprising "neighborhood deprivation" for rural areas and Thus, traditional indicators included in correspondingly, need to identify appropriate neighborhood deprivation indices may not measures be applicable to rural areas Other indicators may be better measures of neighborhood deprivation in rural areas Subject to change over time Short term: Some methodologies available in other surveys (e.g., Health and Retirement Study [HRS]
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From page 524... ...
) Social support No existing data Could be collected No existing data because it can sources change over time, especially for older adults, and has clinical utility, but would require further research on standardized data collection Some measures exist in the literature that could be used
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From page 525... ...
APPENDIX D 525 Other Considerations Proposed Data Collection Strategy May change rapidly among Medicare Long term: Develop measures and methods beneficiaries; therefore, it may best be for collection through EHRs collected periodically in the clinical context May change rapidly among Medicare Long term: Develop measures and methods beneficiaries; therefore, it may best be for collection through EHRs collected periodically in the clinical context continued
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From page 526... ...
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 Acculturation No existing data; Could be accurately No existing data need further research collected with little sources on standardized data burden, but is not collection currently collected Language use could Could have clinical also be used as a utility proxy (see row on language)
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From page 527... ...
(rather than health status generally or access)
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From page 528... ...
Other environ- No existing data No existing data Area-level measure, mental measures needs to be thought about much more as evidence develops; need to wait for more evidence of association with health care outcomes of interest and indicators used in VBP
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From page 529... ...
Could be revisited when more evidence is available, but standardized data collection is needed Preference to collect through EHRs rather than the Medicare intake survey because of the sensitive nature of the information Mode of collection matters for accuracy and this question may be best assessed through a clinical discussion between a patient and a provider Examples of indicators include Long term: Needs further research on the transportation availability and exposure to effect on health care outcomes of interest environmental hazards Could be revisited when more evidence is available, but standardized data collection is needed
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From page 530... ...
TABLE D3-2 Summary of Data Availability for Social Risk Factor Indicators 530
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From page 531... ...
2013. Behavioral Risk Factor Surveil lance System questionnaire.
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From page 532... ...
2015b. Medicare and Medicaid programs; electronic health record incentive program stage 3 and modifications to meaningful use in 2015 through 2017; final rule.
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From page 533... ...
2016a. Accounting for social risk factors in Medicare payment: Identifying social risk factors.
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From page 534... ...
2012. The validity of race and ethnicity in enrollment data for Medicare beneficiaries.
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