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

As required by the IMPACT Act, the second 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. This Report also examined how HHS can achieve better outcomes for all Medicare beneficiaries by facilitating the ability of providers and communities to address social risk factors and integrate health and social services. Empirical analyses for this Report used existing Medicare data and additional, non-Medicare data sources.

See the full Second Report to Congress.

This Report had three major findings:

FINDING 1: Beneficiary social risk information is not routinely or systematically collected across the health care system, and there is not always standardized terminology to capture beneficiary social risk information.

FINDING 2: After accounting for additional social and functional risk factors, dual-enrollment status remains a powerful predictor of poor outcomes on some quality and resource use measures in Medicare’s VBP programs. Functional status is also a powerful predictor of poor outcomes on some measures but is not always included in measure risk adjustment.

FINDING 3: Although many organizations are working to improve equity by addressing social risk, which interventions are effective, replicable, and scalable remains unclear due to limited evaluation.

The report includes recommendations for a comprehensive strategy to account for social risk in Medicare’s VBP programs building on the three-part strategy for accounting for social risk in Medicare’s value-based purchasing programs introduced in the first Report:

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

RECOMMENDATION 1.1. HHS should support and inform the development of data collection and interoperability standards for social risk. CMS should explore ways to encourage providers to collect social risk information.

RECOMMENDATION 1.2. Federal and state agencies should consider policies regarding how and when to share social risk data across agencies. HHS should explore whether some social risk data can/should be shared at the local level between health and social service providers.

RECOMMENDATION 1.3. Quality reporting programs should include health equity measures.

RECOMMENDATION 1.4. Quality and resource use measures should be reported separately for dually enrolled beneficiaries and other beneficiaries.

RECOMMENDATION 1.5. Quality and resource use measures should not be adjusted for social risk factors for public reporting.

RECOMMENDATION 1.6. Composite scores should not be adjusted for social risk factors for public reporting.

STRATEGY 2: Set High, Fair Quality Standards for All Beneficiaries

RECOMMENDATION 2.1. Measure developers and endorsement organizations should create a standard risk-adjustment framework that includes functional risk for all risk-adjusted outcome and resource use measures used in Medicare programs.

RECOMMENDATION 2.2. Value-based purchasing programs should include health equity measures and/or domains.

RECOMMENDATION 2.3. Resource use and patient experience measures should adjust for social risk factors in VBP programs.

RECOMMENDATION 2.4. Process and outcome measures should not be adjusted for social risk in VBP programs.

RECOMMENDATION 2.5. Value-based purchasing programs should not use peer grouping or categorical adjustments for social risk factors. Where these adjustments are currently in place, they should be removed when additional actions and tools are implemented to help providers achieve high-quality care for all beneficiaries.

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

RECOMMENDATION 3.1. CMS should continue to support providers and plans addressing social risk factors through models, supplemental benefits, and VBP payment adjustments. HHS should continue to develop approaches to address beneficiaries’ social needs. Additional research is needed on best practices for providing care to socially at-risk beneficiaries. Best practices, once identified, need to be scaled.

RECOMMENDATION 3.2. Learning networks, such as Quality Improvement Organizations (QIOs), should share best practices across providers.

RECOMMENDATION 3.3. HHS should encourage medical providers and plans to build links with social service providers to better address beneficiaries’ social needs.

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 First Report to Congress.

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

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.

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.

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.

See the interviews and case studies.

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 full report on Incorporating Social Determinants of Health in Electronic Health Records.