Social Risk Factors and Medicare's Value-Based Purchasing Programs: Reports

First Report to Congress

The Improving Medicare Post-Acute Care Transformation Act of 2014 or the IMPACT Act (P.L. 113-185), requires the Secretary, acting through the Assistant Secretary for Planning and Evaluation (ASPE), to conduct research on issues related to social risk in Medicare’s value-based payment programs.

The first Report to Congress examines the effect of individuals’ social risk factors on quality measures, resource use, and other measures under the Medicare program, as well as analyses of the effects of Medicare’s current value-based payment programs on providers serving socially at-risk beneficiaries and simulations of potential policy options to address these issues. Empirical analyses for this Report used existing Medicare data.

See the full report here

This report had two major findings:

FINDING 1: 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.

FINDING 2: 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.

The report proposes for consideration a three-part strategy for accounting for social risk in Medicare’s value-based purchasing programs:

STRATEGY 1: Measure and Report Quality for Beneficiaries with Social Risk Factors

CONSIDERATION 1: Consider enhancing data collection and developing statistical techniques to allow measurement and reporting of performance for beneficiaries with social risk factors on key quality and resource use measures

CONSIDERATION 2: Consider developing and introducing health equity measures or domains into existing payment programs to measure disparities and incent a focus on reducing them

CONSIDERATION 3: Prospectively monitor the financial impact of Medicare payment programs on providers disproportionately serving beneficiaries with social risk factors

STRATEGY 2: Set High, Fair Quality Standards for All Beneficiaries Reward and support better outcomes for beneficiaries with social risk factors

CONSIDERATION 1: Measures should be examined to determine if adjustment for social risk factors is appropriate; this determination will depend on the measure and its empirical relationship to social risk factors.

CONSIDERATION 2: The measure development community should continue to study program measures to determine whether differences in health status might underlie the observed relationships between social risk and performance, and whether better adjustment for health status might improve the ability to differentiate true differences in performance between providers.

STRATEGY 3: Reward and Support Better Outcomes for Beneficiaries with Social Risk Factors

CONSIDERATION 1: Consider creating targeted financial incentives within value-based purchasing programs to reward achievement of high quality and good outcomes, or significant improvement, among beneficiaries with social risk factors. Consideration 1: Consider creating targeted financial incentives within value-based purchasing programs to reward achievement of high quality and good outcomes, or significant improvement, among beneficiaries with social risk factors.

CONSIDERATION 2: Consider using existing or new quality improvement programs to provide targeted support and technical assistance to providers that serve beneficiaries with social risk factors.

CONSIDERATION 3: Consider developing demonstrations or models focusing on care innovations that may help achieve better outcomes for beneficiaries with social risk factors.

CONSIDERATION 4: Consider further research to examine the costs of achieving good outcomes for beneficiaries with social risk factors and to determine whether current payments adequately account for any differences in care needs.

National Academy of Medicine’s Committee on Accounting for SES in Medicare Payment Programs

One requirement from the IMPACT Act is qualitative research related to addressing social risk in Medicare’s value-based purchasing programs. To address this requirement, ASPE commissioned a series of consensus reports from the National Academies of Science, Engineering, and Medicine (NASEM) to

  • Develop a conceptual framework for measuring and evaluating social risk in relation to Medicare payment and quality programs;

  • Identify practices that show promise for improving care for socially at-risk populations;

  • Provide guidance on methods for evaluating social risk; and

  • Identify data sources and evaluate strategies to collect data on social risk factor indicators.

See the committee’s reports here

Services for Dual Beneficiaries by Medicare Advantage Health Plans

ASPE contracted with the RAND Corporation to conduct an environmental scan, interviews, and case studies to identify the types of services that Medicare Advantage plans implement to meet the needs of dually enrolled and other high-cost, high-need beneficiaries, as well as the types of resources needed to implement these services.

See the environmental scan here

See the interviews and case studies here

Incorporating Social Determinants of Health in Electronic Health Records

The ASPE patient-centered outcomes research team contracted with NORC at the University of Chicago to interview electronic health records (EHRs) vendors about the collection and use of social risk information. The interviews sought to a) identify vendors’ motivations to develop social determinant software products, b) describe their products and uses, and c) identify facilitators and challenges to collection and use of social determinant data.

See the report here