Academies Continues Work on Socio-Economic Risk Adjustment

In the latest aspect of its research on socio-economic status for the purpose of its application to Medicare quality measurement and payment programs, the National Academies of Sciences, Engineering, and Medicine has taken a look at the data needed to define socio-economic status.

-academy-of-medicine-274x168In its new report Accounting for Social Risk Factors in Medicare Payment: Data, the Academies, notes that it was hired by the U.S. Department of Health and Human Services to

…convene an ad hoc committee to provide a definition of socioeconomic status for the purposes of application to Medicare quality measurement and payment programs; identify the social factors that have been shown to impact health outcomes of Medicare beneficiaries; specify criteria that could be used in determining which social factors should be accounted for in Medicare quality measurement and payment programs; identify methods that could be used in the application of these social factors to quality measurement and/or payment methodologies; and recommend existing or new sources of data and/or strategies for data collection.

Based on its deliberations, the committee offered seven recommendations addressing data collection:

  1. The committee recommends the Centers for Medicare & Medicaid Services (CMS) use five guiding principles when choosing data sources for specific indicators of social risk to be used in Medicare performance measurement and payment. These guiding principles are
  • CMS should first use data it already has.
  • CMS should second look for opportunities to use existing data collected by other government agencies (including elsewhere in the Department of Health and Human Services).
  • To the extent that a social risk factor is relatively stable, CMS should examine the feasibility of collecting additional data at the time of enrollment in Medicare.
  • 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 environment, existing data sources that can be used to develop area-level measures should be considered. 
  1. 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.
  1. Data for individual measures of race and ethnicity, language, and marital/partnership status and for area-level measures of income, education, and neighborhood deprivation are currently available, and the committee recommends that the Centers for Medicare & Medicaid Services (CMS) use them for performance measurement and payment applications in the short term. However, owing to limitations in these data, CMS should research ways to improve accuracy and collection of individual- level measures of race and ethnicity, language, marital/partnership status, income, and education, as well as an area-level measure of neighborhood deprivation for use in the future.
  1. Individual measures of wealth, living alone, and social support exist, but they are sufficiently limited to preclude their use by the Centers for Medicare & Medicaid Services (CMS) in Medicare performance measurement and payment at this time. Therefore, the committee recommends that CMS research ways to accurately collect data on these indicators. 
  1. Area-level measures exist for housing, but they have limitations for use by the Centers for Medicare & Medicaid Services (CMS) in Medicare performance measurement and payment at this time. The committee recommends that CMS research ways to accurately collect housing data, whether at an individual level or an area level.
  1. The committee recommends that research be conducted on the effect of acculturation, sexual orientation and gender identity, and environmental measures of residential and community context on health care outcomes of Medicare beneficiaries, and on methods to accurately collect relevant data in the Medicare population.
  1. The committee recommends that the Centers for Medicare & Medicaid Services collect information about relevant, relatively stable social risk factors, such as race and ethnicity, language, and education, at the time of enrollment.

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.

Find the complete report of National Academies of Sciences, Engineering, and Medicine here.

A New Approach to Serving High-Cost, High-Need, High-Risk Medicaid Patients

A partnership consisting of a county government, a public hospital, a county-run Medicaid managed care plan, and a federally qualified health center, Hennepin Health is an accountable care organization that seeks to serve high-cost, high-need, high-risk Medicaid patients in the greater Minneapolis area.

Hennepin Health targets such individuals – all childless adults who became eligible for Medicaid when the state expanded its Medicaid program in 2011 – with the help of algorithms, identifies those most likely to incur high medical costs. It then offers a blend of social services, preventive care, and other services to address members’ medical conditions while bringing stability and order to their lives. Seventy-five percent of the program’s members are male, 70 percent are non-white, half lack stable housing, two-thirds suffer from mental illness, 80 percent have substance abuse problems, and 19 percent suffer from chronic pain.

These are the very kinds of patients typically served in especially high numbers by private safety-net hospitals.

The results of the program have been encouraging: the program has improved participants’ access to primary care, reduced emergency room visits, and stabilized the health of participants with chronic medical conditions.   While hospitalizations have not declined, medical costs have fallen an average of 11 percent a year since 2012.

Happy medical team of doctors togetherLed by the county government, Hennepin Health currently serves 12,000 members whose care is financed by Medicaid, with the county assisting with the cost of social services. All four ACO partners invested an initial $1.6 million for staff and data infrastructure and have assumed full financial risk for the venture.

Learn more about how one program is seeking to make a difference in the lives of high-risk, high-need patients while reducing high health care costs in the article “Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries,” which can be found here, on the web site of The Commonwealth Fund.

New Study Questions 30-Day Readmissions as Measure of Hospital Quality

Hospital readmissions within 30 days of discharge may not be a good way of judging the quality of care hospitals provide, a new study suggests.

Seven days may be more like it.

According to a new study published in the journal Health Affairs, the impact of the quality of care a hospital provides appears to be most evident immediately upon patients’ discharge from the hospital.

Further, the study suggests,

… most readmissions after the seventh day postdischarge were explained by community- and household-level factors beyond hospitals’ control.

The researchers’ conclusion?

Shorter intervals of seven or fewer days might improve the accuracy and equity of readmissions as a measure of hospital quality for public accountability.

health affairsThe findings call into question the approach employed by Medicare through its’ hospital readmissions reduction program.

NAUH has long opposed the manner in which Medicare’s readmissions reduction program is constructed and has urged the Centers for Medicare & Medicaid Services to revise it by taking into consideration the distinct challenges private safety-net hospitals face when applying its 30-day standard – the very kind of challenges, such as community and household factors, cited in the study. Earlier this year NAUH endorsed legislation in Congress – H.R. 1343 and S. 688, the Establishing Beneficiary Equity in the Hospital Readmissions Program Act – and in a letter to CMS calling for change in the program as well.

To learn more about how the study was performed and what its implications might be, go here to see the Health Affairs study “Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care.’

Foundation Looks at Care for High-Need, High-Cost Patients

In a new issue brief, the Commonwealth Fund has identified what it views to be six key elements for improving care for high-need, high-cost patients – those who consume disproportionate amounts of health care. They are:

  • Promote value-based payments
  • Improve value-based payment design and implementation
  • Allow payments for non-medical services
  • Assist clinicians in adopting best practices
  • Prioritize health information exchange
  • Support ongoing presentation

commonwealth fundPermitting payments for non-medical services is especially important for private safety-net hospitals. As the issue brief notes, and as private safety-net hospitals have long observed, meeting the housing, nutrition, social, and other personal needs of high-care, high-cost patients can play as great a role in their overall health as the medical services they receive.

Learn more about what these options are and why they are important in the Commonwealth Fund issue brief “Tailoring Complex Care Management for High-Need, High-Cost Patients.”

Senate May Tackle Socio-economic Risk Adjustment

With a House bill to adjust Medicare payment penalties based upon the socio-economic challenges posed by the patients some hospitals serve folded into a House bill that passed in June, the Senate may take up this issue during its fall session.

Health economists, policy experts, and providers generally agree that the performance of hospitals that serve especially large numbers of low-income patients is affected in a number of areas, including Medicare readmissions, meeting value-based purchasing criteria, and others.

And while the Centers for Medicare & Medicaid Services acknowledges the challenge, the agency has rejected calls for risk adjustment so far, repeatedly writing that it does not “want to mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations.”

HospitalMeanwhile, a growing body of research has documented that the anticipated impact of serving socioeconomically challenged patients is real and more and more people are joining the call for Congress or CMS to address the problem.

Compounding the challenge is that hospitals that serve such patients are faced with growing financial penalties from Medicare if they fail to perform at levels comparable to hospitals that face fewer challenges.

NAUH has long argued that Medicare’s quality-related programs need appropriate risk adjustment and support H.R. 1343, the Establishing Beneficiary Equity in the Hospital Readmissions Program Act, which was folded into other House legislation in June, and S. 688, a bill of the same name in the Senate. Go here to see NAUH’s letter conveying its support for this legislation.

For a closer look at the issue, the arguments on both sides, and the prospects for congressional action this fall, see this article from CQ Roll Call presented by the Commonwealth Fund.

Hospital Group Models Risk-Adjusted Medicare Readmissions

The Missouri Hospital Association has published data that demonstrates that risk-adjusting Medicare readmissions based on social determinants of health reduces the readmission rates of hospitals that care for large numbers of low-income patients.

The data, modeling, and risk adjustment methodology, developed by the association based on data from Missouri hospitals, published on the association’s “Focus on Hospitals” web site, and described in an article on the NEJM Catalyst web site, showed that

SDS [note:  sociodemographic status)-enriched models yielded significant relative reductions in the range of risk-standardized readmission ratios for each of…6 outcomes…Overall, SDS enrichment best improved the 30-day readmission assessments of hospitals that served higher concentrations of Medicaid patients and higher-poverty communities.

iStock_000005787159XSmallThe lack of risk adjustment for socioeconomic risk factors has been a controversial aspect of Medicare’s hospital readmissions reduction, with a growing body of research suggesting that without such risk adjustment, the program is unfair to hospitals that care for especially large numbers of low-income patients.  The National Association of Urban Hospitals has long protested the lack of risk adjustment in the readmissions reduction program and earlier this year endorsed H.R. 1343 and S. 688, both titled the Establishing Beneficiary Equity in the Hospital Readmissions Program Act, which would require the Centers for Medicare & Medicaid Services to add a risk adjustment component to the program.  See an NAUH letter endorsing the bills here.

Learn more about the work done by the Missouri Hospital Association, and its implications, in its report Risk Adjustment for Sociodemographic Status in 30-Day Hospital Readmissions and this description of and commentary on the association’s research on the NEJM Catalyst web site.


Journal Looks at Health Disparities

The journal Health Affairs looks at health disparities and social determinants of health in its August 2016 issue.

health affairsThe article “Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health” looks at interventions that focus on social determinants of health, addresses how such interventions can reduce health disparities and improve population health, and considers the challenges to implementing such approaches. Find it here.

The article “Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research” also looks at health care disparities and how to address them, focusing on cardiovascular disease and cancer. Find it here.

Communities served by private safety-net hospitals usually suffer from the very health disparities policy-makers are currently working to address.

NIH Launches Research on Health Disparities in Disadvantaged Communities

The National Institutes of Health is launching a new Transdisciplinary Collaboratives Centers for Health Disparities Research on Chronic Disease Prevention program that seeks to respond to

…the need for more robust, ecological approaches to address chronic diseases among racial and ethnic minority groups, under-served rural populations, people of less privileged socio-economic status, along with groups subject to discrimination who have poorer health outcomes often attributed to being socially disadvantaged. Two centers will focus their research efforts on development, implementation, and dissemination of community-based, multilevel interventions to combat chronic diseases such as heart disease, cancer and diabetes.

NIH_Master_Logo_Vertical_2ColorAnticipated funding over the first five years of the program is approximately $20 million.

In announcing the program, the NIH noted that

Heart disease, stroke, cancer, diabetes, and arthritis are among the most common, costly and preventable of all health problems. Many of these conditions disproportionately affect health disparity populations and in advanced stages can lead to significant limitations in activities of daily living.

These are the very health challenges that private safety-net hospitals tackle regularly – and far more often than the typical community hospital.

To learn more about what the program seeks to accomplish and the health challenges it anticipates addressing, see this NIH news release.

Medicare Continues to Grapple With Socio-Economic Risk Adjustment

The question of whether Medicare should consider the socio-economic status of the patients hospitals serve when it judges the effectiveness and quality of care hospitals provide continues to stir discussion and debate in the health care community.

The issue arose recently in the context of the Centers for Medicare & Medicaid Services’ new star ratings of hospitals, which some groups maintained could be unfair to hospitals that serve especially high proportions of low-income patients.

The same issue has arisen in discussions about the fairness of Medicare’s hospital readmissions reduction program, with legislation seeking to address this currently before Congress, and could arise again soon as CMS continues to implement its new merit-based incentive payment system (MIPS).

Proponents of adjusting ratings based on the socio-economic status of the patients hospitals serve maintain that such providers should not be penalized for challenges beyond their control. Those who oppose such adjustments do not want CMS to “…mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations.”

iStock_000001497717XSmallThe National Association of Urban Hospitals has long called for socio-economic risk adjustment of Medicare’s readmissions reduction program (most recently here), maintaining that the large numbers of low-income patients private safety-net hospitals serve are more challenging to treat than typical hospital patients and more likely to require post-discharge readmission to address continuing medical and social issues. NAUH has endorsed H.R. 1343, the Establishing Beneficiary Equity in the Hospital Readmissions Program Act, and S. 688, a bill of the same name in the Senate, both of which would direct CMS to introduce such risk adjustment to the program.

CMS continues to study the issue. Even as it awaits the results of a two-year review by the National Quality Forum, its Office of the Assistant Secretary for Planning and Evaluation is performing its own analysis as part of a broader effort to reform Medicare post-acute care payments.

For a closer look at this issue, see this article from CQ Roll Call presented by the Commonwealth Fund.

Docs Less Likely to Participate in ACOs in Disadvantaged Communities

A new study has found that physicians who practice in areas with higher proportions of low-income, uninsured, less-educated, disabled, and African-American residents are less likely than others to participate in accountable care organizations.

If ACOs ultimately are found to improve health care quality while better managing costs, their benefits might be limited in such communities, thereby exacerbating health care disparities.

It also would be disadvantageous to many of the communities served by the nation’s private safety-net hospitals.

health affairsTo learn more, go here to see the Health Affairs report “Physicians’ Participation In ACOs Is Lower In Places With Vulnerable Populations Than In More Affluent Communities.”