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.

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.