Medicare Penalizes Hospitals for Avoidable Injuries, Illnesses

Medicare is reducing payments to 751 hospitals because of the high rate at which their patients have suffered avoidable injuries and illnesses while in the hospital.

The penalties come under Medicare’s Hospital-Acquired Condition Reduction Program, which was established by the Affordable Care Act.

Among the penalized hospitals,

  • more than half were penalized last year as well
  • 115 are academic medical centers – about one-third of all such facilities
  • more than one-third of all safety-net hospitals were penalized

Over the years NAUH has argued that the program is unfair to private safety-net hospitals because it fails to give any weight to the additional challenges such hospitals face because of the socio-economic risk factors of the communities and patients they serve.

Learn more about the program, the penalties, and why the penalties were assessed in this Kaiser Health News report.

New Help With Addressing Low-Income Patients’ Social Services Needs?

One of the long-time barriers to states and hospitals addressing low-income patients’ social services needs and the social determinants of health has been a lack of resources for such assistance.  Medicaid, in particular, has not been a financial participant in such efforts.

But that may be changing.

The new federal Medicaid managed care regulation, updated nearly two years ago, allows for the inclusion of some non-clinical services as covered Medicaid services and for funding for such services to be folded into Medicaid managed care plans’ capitation rates and medical loss ratios.  The updated regulation also encourages greater coordination of care for Medicaid patients and coverage for long-term services and supports in the home and community for medically qualified patients.

Because they serve so many low-income patients, private safety-net hospitals are especially interested in policy changes that might enable them to serve such patients more effectively.

The Commonwealth Fund has taken a closer look at how the 2016 Medicaid managed care regulation may facilitate addressing the psycho-social needs of Medicaid beneficiaries.  Go here to see its report “Addressing the Social Determinants of Health Through Medicaid Managed Care.”

Serving High-Risk Patients Leads to VPB Penalties

Practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for high-risk practices.

So concludes a new study that looked at the results of the first year of the Medicare Physician Value-Based Payment Modifier Program.

The study looked at 899 physician practices serving more than five million Medicare beneficiaries, and it points to the continuing challenge of how best to serve patients who pose greater socio-economic risks than the average patient.

Private safety-net hospitals serve far more high-risk patients than the typical American hospital.

Learn more these findings and how they were reached in the study “Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program,” which can be found here, on the web site of the Journal of the American Medical Association.

New Book Addresses Social Risk Factors in Medicare

In the new book Accounting for Social Risk Factors in Medicare Payment, the National Academies of Sciences, Engineering, and Medicine addresses the question of what social risk factors might be worth considering in Medicare value-based payment programs and how those risk factors might be reflected in value-based payments.

The book, the culmination of a five-part NASEM process, focuses on five social risk factors:

  • socio-economic position
  • race, ethnicity, and cultural context
  • gender
  • social relationships
  • residential and community context

Addressing such factors in Medicare value-based payments, the book finds, can help achieve four important goals:

  • reduce disparities in access, quality, and outcomes
  • improve the qualify and efficiency of care for all patients
  • foster fair and accurate reporting
  • compensate provides fairly

Doing so also can help prevent five types of unintended consequences from a failure to address social risk factors in Medicare payment policy:

  • providers avoiding patients with social risk factors
  • reducing incentives to improve the quality of care for patients with social risk factors
  • underpaying providers that serve disproportionately large numbers of patients with social risk factors
  • a perception of different medical standards for different populations
  • obscuring disparities in care and outcomes

NAUH has long advocated appropriate consideration in Medicare payment policies of the special challenges poses by the patients and communities served by private safety-net hospitals.

Learn more about social risk factors and their potential role in Medicare value-based payment policy in the new book Accounting for Social Risk Factors in Medicare Payment, which can be downloaded free of charge here, from the web site of the National Academies of Sciences, Engineering, and Medicine.

Serving High-Need, High-Cost Medicare Patients

With Medicare beneficiaries who have four or more chronic conditions accounting for 90 percent of Medicare hospital readmissions and 74 percent of Medicare costs (both 2010 figures), policy-makers are constantly looking for better ways to serve such individuals.

Academic research suggests that these beneficiaries need a variety of non-medical social interventions and supports, most of which are not covered by Medicare.

With this in mind, the Bipartisan Policy Center has prepared a review of current regulatory, payment, and other barriers that prevent providers and insurers from meeting some of the non-medical needs of high-need, high-cost patients that result in such high health care costs and hospital readmissions rates.

Many of these high-need, high-cost patients live in low-income communities served by private safety-net hospitals, making this a subject of particular interest to NAUH and its members.

Many of these high-need, high-cost patients live in low-income communities served by private urban safety-net hospitals, making this a subject of particular interest to NAUH and its members.

Among the care models this review considers are Medicare Advantage plans, Medicare Advantage Dual-Eligible Special Needs Plans, Medicare Shared Savings Program Accountable Care Organizations, Next Generation ACOs, Comprehensive Primary Care Plus Model Participants, and Programs for All-Inclusive Care for the Elderly (PACE).

Find this all in the Bipartisan Policy Center report Challenges and Opportunities in Caring for High-Need, High-Cost Medicare Patients, which is available here.

Defining “Success” in Addressing Social Determinants of Health

With a growing number of programs designed to address the social determinants of individuals’ health care challenges, the question arises as to how to define “success” in those approaches.

A recent article on the Health Affairs Blog addresses this question by illustrating the many variables that go into determining what constitutes “success” and suggesting that success be viewed from a number of perspectives, including:

  • success for entire communities
  • success from the perspective of individual patients
  • success based on the effectiveness of addressing specific social needs (such as housing, transportation, or food security)

The article also describes the different ways that success can be defined and measured.

This is an especially important matter for urban safety-net hospitals because so many of these new programs will be launched in the generally low-income communities they serve.

Learn more by reading the article “Defining Success In Resolving Health-Related Social Needs,” which can be found here.

Academies Completes Work on Social Risk Factors in Health Care

Completing its assignment from the U.S. Department of Health and Human Services, the Health and Medicine Division of the National Academies of Science, Engineering, and Medicine has published its fifth and final report on social risk factors that affect health outcomes for Medicare beneficiaries and how to account for those risk factors in Medicare payments.

PrintAmong other things, the report notes that

Although VBP [value-based purchasing] 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 generally not reflected in payment under current VBP design. This misalignment has led to concerns that trends toward VBP could harm socially at-risk populations: Providers disproportionately serving socially at-risk populations are more likely to score poorly on performance/quality rankings, more likely to be penalized financially, and less likely to receive bonus payments under VBP. VBP may be taking resources from the organizations that need them the most.

The risk factors the Academies considered were socioeconomic position; race, ethnicity, and cultural context; gender; social relationships; and residential and community context.

The Academies’ fifth and final report brings together its first four efforts.

  • The first report, Accounting for Social Risk Factors in Medicare Payment Programs: Identifying Social Risk Factors, presented a conceptual framework and the results of a literature search linking social risk factors to health-related measures.
  • The second report, System Practices for the Care of Socially At-Risk Populations, explored six patient-centered systems practices that show potential for improving care for socially at-risk communities.
  • The third report, Accounting for Social Risk Factors in Medicare Payment: Criteria, Factors, and Methods, offered guidance on social risk factors might be incorporated into future Medicare payment systems.
  • The fourth report, Accounting for Social Risk Factors in Medicare Payment: Data, offered data strategies and solutions for collecting data to measure social risk factors that might be addressed in future Medicare payment systems.

The fifth and final report, Accounting for Social Risk Factors in Medicare Payment, offers additional thoughts and recommendations for next steps.

The subject of socio-economic risk adjustment has long been of great interest to the National Association of Urban Hospitals because so many of the patients private safety-net hospitals serve present with such risk factors.  NAUH has long maintained that Medicare payment systems and innovation programs need to be risk-adjusted to reflect these additional risk factors.

Find the new report here.

New Study: Social Risk Factors Affect Provider Performance and Patient Outcomes

Medicare patients with social risk factors fare worse than others in programs that measure quality and the providers that serve them also perform worse than others on quality measures.

This news comes from a new report presented to Congress by the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Planning Evaluation.

ASPEsealThe report, mandated by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, focused on nine Medicare payment programs:

  1. the hospital readmissions reduction program
  2. the hospital value-based purchasing program
  3. the hospital acquired condition reduction program
  4. the Medicare Advantage (Part C) quality star rating program
  5. the Medicare shared savings program
  6. the physician value-based payment modifier program
  7. the end-stage renal disease quality incentive program
  8. the skilled nursing facility value-based purchasing program
  9. the home health value-based purchasing program

APSE concluded that:

  • Beneficiaries with social risk factors had worse outcomes on many quality measures, regardless of the providers they saw, and dual enrollment status was the most powerful predictor of poor outcomes.
  • Providers that disproportionately served beneficiaries with social risk factors tended to have worse performance on quality measures, even after accounting for their beneficiary mix. Under all five value-based purchasing programs in which penalties are currently assessed, these providers experienced somewhat higher penalties than did providers serving fewer beneficiaries with social risk factors.

Among the solutions suggested in the report for addressing these problems are:

  • adjusting quality and resource use measures
  • adjusting payments
  • addressing the underlying issues

The report also suggests that HHS’s strategy for accounting for social risk in Medicare’s value-based purchasing programs should consist of the following three steps:

  • measure and report quality for beneficiaries with social risk factors
  • set high, fair quality standards for all beneficiaries
  • reward and support better outcomes for beneficiaries with social risk factors

And in carrying out these steps, the report recommends that HHS

  • provide specific payment adjustments to reward achievement and/or improvement for beneficiaries with social risk factors, and
  • where feasible, provide targeted support for providers who disproportionately serve them.

NAUH has long maintained that some of Medicare’s quality-related programs are unfair to private safety-net hospitals because of the socio-economic challenges faced by so many of the patients these hospitals serve.  The APSE analysis confirms NAUH’s view on this issue.

Learn more about the problems APSE found and its proposals for dealing with those problems by reading Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs.

Social Determinants and Health Care

Amid growing recognition that social factors play at least much a role in the health of communities as medical care, growing attention is being paid to how best to address those social determinants in a health care system.

With increasing use of alternative delivery models such as accountable care organizations, some approaches place health care at the heart of a hub-and-spoke model to address population health, supported by functions such as affordable housing, home health care, job training, and more. Another approach places community organizations at the hub of care models, with the health care system as a spoke feeding into that hub.

Stock PhotoSocio-economic issues that affect the health of communities are among the biggest challenges private safety-net hospitals face ­– challenges that take them well beyond their ability to provide quality care to their patients.

A recent article on the Health Affairs Blog explores the hub-and-spoke approach to addressing the social determinants that play such a major role in population health. Go here to read the blog article “Defining The Health Care System’s Role In Addressing Social Determinants And Population Health.”

More Evidence Supports Shortcomings of Medicare Readmissions Penalties

A new study supports the belief that Medicare’s hospital readmissions reduction program is unfair to hospitals that serve especially large numbers of low-income patients.

A study published in the journal Surgery found that hospitals that serve larger numbers of minority patients have higher 30-day and 90-day readmissions rates for patients who undergo colorectal surgery than other hospitals.

Surgical InstrumentsAccording to the study, 65 percent of the increased risk of readmission can be attributed to “patient factors,” as opposed to hospital factors, with study data suggesting that such factors include income, race, and insurance status.

NAUH has long maintained that Medicare’s hospital readmissions reduction program needs to be risk-adjusted, arguing that the program treats private safety-net hospitals unfairly because it fails to recognize the special challenges they face when serving the residents of the low-income communities in which they are located. Most recently, it conveyed these concerns to the Centers for Medicare & Medicaid Services in a letter about the FY 2017 Medicare inpatient prospective payment system and by supporting legislation currently before Congress that would address this issue.

For a closer look at the study’s findings see this Fierce Healthcare report.