For some time now, home health care providers have noted that some the measures used by Centers for Medicare & Medicaid Services (CMS) to rate the quality of care don’t always tell the whole story. In many cases, social factors — including race, education, or income — play a significant role in a patient’s progress, and in the way that they respond to care. In a sense, providers argue, CMS is comparing apples to oranges when it comes to rating and ranking agencies against each other, as not all agencies work with similar populations and may face challenges that other agencies do not.
In response to these concerns, and in an effort to comply with the IMPACT Act, CMS is considering the addition of social risk factors to Medicare quality reporting. As announced in early August, the agency is seeking public comment on whether social factors should be included, and if so, which factors should be accounted for. This is in line with recommendations published in the New England Journal of Medicine earlier this year, which identified four key reasons that social risk factors in Medicare, both in terms of quality reporting and payment programs.
First, accounting for social risk factors helps address in access, quality, and outcomes among patients and providers. Second, it helps improve the quality and efficient care delivery for all patients, while also ensuring fair and accurate reporting among all providers as well as fair compensation for all providers, but most especially those who have a disproportionate number of patients with more risk factors.
The Goals of IMPACT
One of the key provisions of the IMPACT Act of 2014 was to develop standardized patient assessment data and corresponding quality measures across the Post-Acute Care (PAC) providers of Medicare services, including home health. However, this requires CMS to compare data from home health, as well as long term care providers, skilled nursing facilities, and inpatient residential facilities. Therefore, CMS wants to define “standardized patient assessment data” as patient or resident assessment questions and response options that are identical in all four PAC assessment instruments, and to which identical standards and definitions apply.
An obvious problem is that using the same standards for everyone does not take into account those factors that could have a profound influence on outcomes, which in turn, have a negative effect on quality ratings. For example, a patient with less education who lives in a rural area is likely to face more challenges in managing a condition than someone living in an urban area who has a college degree — just as someone who has a lower income is facing different challenges than someone who has more money. When you are trying to make ends meet, and have limited funds for medication, healthy foods, or even adequate housing, following doctors’ instructions can be a challenge.
The idea of adjusting measures to compensate for social risk factors isn’t new. The National Quality Forum already has a demonstration underway to determine how measures should be adjusted for social risk. During this two-year trial period, the NQF is adjusting measures from the for Re-hospitalization During the First 30 Days of Home Health and Emergency Department Use without Hospital Readmission During the First 30 Days of Home Health for social risk factors. When the trial concludes, NQF will issue additional recommendations on risk adjustment for quality measures, and which factors should be included, if any.
Addressing Potential Consequences
While most government leaders, as well as home health industry leaders, agree that social risk factors should not be ignored, there is concern about the potential consequences that adjusting quality measures and compensation based on these factors could bring. In short, some fear that including risk factors will undoubtedly reward high-quality care, but could also potentially “excuse” lower quality care because the patients receiving it meet certain criteria. Some fear that adding these risk factors effectively gives providers in traditionally low-income or underserved areas an excuse for not meeting quality standards, and could eventually lead to even greater disparities in the quality of care.
Collecting information has also been cited as a concern, as some question how these influencing factors will be determined. However, Medicare already has information related to many of the most influential characteristics, including income, race, sex, and address. Home health agencies can be instrumental in collecting additional data, using their medical record software to maintain detailed information about their patients that can be used in calculating quality scores.
Proponents note that including risk factors in quality measures isn’t designed to create lower standards for some providers, and they will still be expected to meet quality standards. By adjusting their performance ratings to account for factors that they cannot control creates a more level playing field, and ensures that ratings and payments are more accurate and fair. And collecting the required information shouldn’t be an obstacle, as it is already a part of the care process for most people.
The public comment period for the Calendar Year (CY) 2018 Home Health Prospective Payment System Rate Update proposed rule, under which the social risk factors rules appear, is open until September 25. After that, CMS will consider how — or if — to move forward.