Home Health & Hospice Week

CMS punts on sociodemographic standards.

As with Value-Based Purchasing, numerous proposed rule commenters told Medicare they doubt risk adjustment is going to take care of patient inequities when it comes to calculation of the four new IMPACT Act-required quality measures.

The risk adjustment concern mentioned most often in the 89 comment letters on the 2017 Home Health Prospective Payment System proposed rule was the lack of sociodemographic or socioeconomic status. “As a not for profit home care provider we accept all referrals irrespective of payment source,” said Eastern Maine HomeCare in its comment letter to the Centers for Medicare & Medicaid Services.

“Our mission driven service model results in significant patient populations that are poor, often living in rural communities, all with significant disease burden. The business model of our for profit competitors targets higher margin Medicare and commercially covered patient referrals placing a larger burden on our organization to serve the most challenging patients,” said the agency that includes VNA Home Health Hospice, Visiting Nurses of Aroostook, Bangor Area Visiting Nurses, and Hancock County HomeCare.

Do this: “We strongly encourage CMS to consider socioeconomic factors in any risk adjustments to a potentially preventable readmission measure,” said Advocate at Home in Downers Grove, Ill., in its comment letter.

“HH agency performance … is impacted by sociodemographic factors,” insisted the Mayo Clinic in its comment letter. “We are concerned that, without sociodemographic adjustment, providers caring for poorer and sicker patients will appear to perform worse on some outcome measures than others treating a different patient population.”

Unfair: “Measures that fail to adjust for sociodemographic factors when there is a conceptual and empirical relationship between those factors and the measure outcome lack credibility, unfairly portray the performance of providers caring for more complex and challenging patient populations, and may serve to intensify health care disparities,” Mayo warned. “We strongly urge CMS to assess each measure for the impact of such factors, and incorporate sociodemographic adjustment where necessary.”

CMS does agree to consider the issue. The National Quality Forum “is currently undertaking a 2-year trial period in which new measures and measures undergoing maintenance review will be assessed to determine if risk-adjusting for sociodemographic factors is appropriate,” the final rule says. “This trial entails temporarily allowing inclusion of sociodemographic factors in the risk adjustment approach for some performance measures. At the conclusion of the trial, NQF will issue recommendations on future permanent inclusion of sociodemographic factors.”

CMS “has tested sociodemographic factors in the measures’ risk models and made recommendations about whether or not to include these factors in the endorsed measures,” the agency explains. “We intend to continue engaging in the NQF process as we consider the appropriateness of adjusting for sociodemographic factors.”

Don’t count on it: However, CMS spends considerable time explaining why its risk adjustment methodology is sound for various HHQRP and Value-Based Purchasing measures and purposes.