HHS quietly released a report to Congress Wednesday on the controversial topic of social risk factors in value-based payment programs, acknowledging that patients with certain risk factors fare worse on many quality measures, and that their providers perform worse, too.
The report—the first of two reports the Office of the Assistant Secretary for Planning and Evaluation is required to publish under the 2014 Improving Medicare Post-Acute Care Transformation Act— examined nine Medicare payment programs, including the Hospital Readmissions Reduction Program and the Medicare Shared Savings Program.
It found that Medicare beneficiaries with social risk factors fared worse on process, clinical outcome and patient experience measures. The most powerful predictor of poor performance was dual eligibility status--which describes people who qualify for both Medicare and Medicaid because they are some combination of disabled, elderly and low-income.
The report also found that providers who disproportionately served patients with social risk factors tended to perform worse on quality measures, including in all five CMS programs that levy penalties on hospitals.
The subject of social risk factors, such as income, race and ethnicity and geography, is controversial. As providers like hospitals and physicians increasingly are rewarded and penalized based on value of the care they provide, they do not want to be punished for factors beyond their control.
HHS has set a goal of tying 90% of traditional Medicare dollars to quality and efficiency performance by 2018. By that year, Medicare spending is projected to be $574 billion.
As the report explains, if patients have poor health outcomes because they receive poor care, value-based payments can drive improvements. But if they have worse health outcomes because of social risk factors, also referred to as social determinants of health, “value-based payment models could do just the opposite.”
Risk adjustment has sparked much debate in discussions of Medicare's quality incentive programs. Providers and their advocates are clamoring for patients' socioeconomic status to be factored into performance results, warning that without such adjustments, providers that are penalized for taking on sicker, poorer patients might refuse to see such patients.
“We must guard carefully against any value-based purchasing arrangements that would lead some providers to decide against serving those individuals with social risk factors,” wrote Dr. Patrick Conway, CMS acting principal deputy administrator and chief medical officer, and Kathryn Martin, the acting assistant secretary for planning and evaluation at HHS, in a blog post Wednesday.
In the past, the CMS has been wary of adjusting for socioeconomic factors, arguing that such handicaps would lead to a two-tiered health system that allows lower-quality healthcare for certain patients.
But Congress recently forced the agency's hand on its hospital readmissions reduction program. The 21st Century Cures Act called for stratifying hospitals by the socioeconomic status of patients, as measured by their proportion of dual eligible patients, to allow apples-to-apples comparisons of hospitals under the program.
