Pursuing Equity and Care Improvement through Fair and Transparent Measurement

The 130 million Americans we serve through the Medicare and Medicaid programs reflect the diverse fabric of our nation. Our beneficiaries represent all walks of life and come to us through varied journeys. Regardless of their income, education, race and ethnicity, employment, community resources, or social support, we strive to make sure all our beneficiaries have access to the highest quality care. We have long recognized how medical risk factors like age, high blood pressure, or high cholesterol can impact people’s health. With renewed emphasis on consumer-focused care, we are increasingly learning that social risk factors, such as income, education, race and ethnicity, play an important role in people’s health.

The goal of many of the health reforms that the Department of Health and Human Services (HHS) has implemented has been to build a health care system that delivers better care and better health to patients, and spends dollars more wisely. To do that, we are tying payment to the quality and efficiency of health care delivered, through value-based or alternative payment models.

As incentives to improve beneficiaries’ health evolve, questions have been raised about whether, and how, social risk factors should be taken into account when assessing providers’ performance on quality and efficiency. Value-based payment has the potential to drive improvements in care and reduce disparities by holding providers accountable for the care provided to individuals with social risk factors. On the other hand, providers should not be held entirely accountable for patient outcomes that are beyond their control, and 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.

In the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), Congress directed the Office of the Assistant Secretary for Planning and Evaluation (ASPE) to study this issue and report back. Today, ASPE released the first of two Reports to Congress that analyze the effect of social risk factors on Medicare quality and resource use measures, and on quality-based payment programs under Medicare.   

ASPE’s initial analysis concludes that beneficiaries with the social risk factors examined have poorer outcomes on many, though not all, quality measures, regardless of which providers they see.  Of the social risk factors examined, dual enrollment in Medicare and Medicaid was the most powerful predictor of poor outcomes.  At the same time, providers that disproportionately furnish care to beneficiaries with social risk factors have poorer performance on many, though not all, quality measures, even after adjusting for the differences in the populations they serve.   The available research does not, however, provide a complete explanation for why these disparities exist. 

These findings suggest that solutions to address disparities will need to focus both on improving outcomes for at-risk beneficiaries and on improving quality for certain providers, as well as on continuing research to better-understand the causes of these disparities.

The report provides detailed analysis of several Medicare quality programs and offers approaches to consider with regard to these difficult, complex, and intertwined problems using a three-part strategy:

1. Measure and Report Quality for Beneficiaries with Social Risk Factors.
2. Set High, Fair Quality Standards for All Beneficiaries.
3. Reward and Support Better Outcomes for Beneficiaries with Social Risk Factors.

Work related to many of these strategies is already underway. As part of our efforts to continually enhance our public reporting and our value-based payment programs, CMS is studying how to incorporate ASPE’s findings into our policies, including how to leverage value-based purchasing programs to help reduce health disparities.

For example, CMS has made it a priority to increase understanding and awareness of health disparities through such specific recent efforts as the CMS Equity Plan to Improve Quality in Medicare, the Mapping Medicare Disparities Tool, and From Coverage to Care. The Mapping Medicare Disparities Tool presents health-related measures from Medicare claims by sex, age, dual eligibility for Medicare and Medicaid, race and ethnicity, and state and county. It provides users a quick and easy way to identify areas with large numbers of vulnerable populations to target interventions that address racial and ethnic disparities. In addition, CMS uses quality improvement programs, such as the Quality Innovation Networks-Quality Improvement Organizations and other Quality Networks, to support providers seeking to improve care for beneficiaries with social risk factors.

In addition, CMS has been posting star ratings for different facilities for a decade and has found that publicly available data drive improvement in care, better reporting, and more engagement in care processes by Medicare beneficiaries. For Medicare Part C and D Star Ratings, CMS is implementing an interim analytical adjustment to address differences in performance for low income subsidy, dually eligible, and disabled beneficiaries while the measure stewards undertake a comprehensive review of their measures used in the Star Ratings Program and ongoing research continues in this area.

CMS plans to work with stakeholders to consider how we might publicly report quality measures for groups of beneficiaries with social risk factors. CMS will also analyze the effect of dual eligible status on performance on resource use measures, and we are already examining whether our post-acute care health assessment instruments could be used to capture patient-level data elements that would allow us to better account for social risk factors when measuring quality performance.

ASPE will continue its work on this issue as well. We will undertake additional studies for the second report to Congress, focusing on a broader set of social risk factors examining how alternative data sources, such as information from surveys or electronic health records, may further enhance our ability to measure, understand, and address these complex issues.

As we move forward to evaluate these findings and identify solutions to reducing disparities, we will seek input on what tools are at our disposal to improve access to high quality care, improve health outcomes for all beneficiaries, particularly for beneficiaries with social risk factors, and continuously drive quality improvement and the elimination of disparities.