The Need to Incorporate Additional Patient Information Into Risk Adjustment for Medicare Beneficiaries

Abstract

This Viewpoint discusses concern that current risk adjustment models used by CMS to tie payment to performance do not account for dementia, frailty, and social risk, and proposes ways to add reliable measures of each to the agency’s CMS-HCC model to more equitably reimburse clinicians and facilities caring for patients with challenging conditions.

Ambulatory Follow-up and Outcomes Among Medicare Beneficiaries After Emergency Department Discharge

“…Our results are consistent with numerous studies documenting socioeconomic disparities in health care access and outcomes. 17 , 23 , 26 , 33 , 34 , 35 While insurance type is an important determinant of access, we observed disproportionately lower rates of follow-up among non-White and Medicaid-eligible beneficiaries, even among traditional Medicare beneficiaries. 12 , 17 Several factors likely contribute to these disparities, including racial discrimination in scheduling appointments, barriers to accessing nonemergency transport, and limited Medicaid expansion, less generous benefits, and a higher threshold for eligibility in some rural states.…”

“… 3 , 39 , 40 These findings also serve as further evidence that hospitals serving populations in areas with disproportionately fewer resources may be penalized for factors beyond their control. 34 , 41 …”

Assessment of Common Comorbidity Phenotypes Among Older Adults With Knee Osteoarthritis to Inform Integrated Care Models

“…Other classification schemes such as comorbidity counts and weighted indices do not fully account for complex interactions among medical conditions, highlighting one of the inherent limitations of current risk adjustment and evaluation processes. 13,14,49 An additional strength of this study is the robust dataset used to evaluate health care use in older adults and to develop a matched comparison group. As a result, we have a strong indication of which conditions are likely to be unique among older adults with KOA compared to those without OA.…”

Comparison of Performance of Psychiatrists vs Other Outpatient Physicians in the 2020 US Medicare Merit-Based Incentive Payment System

“…Prior research shows that Medicare clinicians with larger caseloads of patients with these characteristics perform worse on the MIPS and other value-based payment programs, perhaps because of inadequate risk adjustment for social risk factors. 40 , 41 , 42 In addition, Medicare does not risk adjust for the most prevalent forms of depression and anxiety disorders, and prior research shows that this inadequate risk adjustment results in underestimation of the resources required to treat beneficiaries with these conditions. 42 , 43 Treating patients with more social risk factors further increases the complexity of psychiatric visits and requires more resources for treatment, compounding the increased costs of caring for patients with mental health disorders.…”

“… 40 , 41 , 42 In addition, Medicare does not risk adjust for the most prevalent forms of depression and anxiety disorders, and prior research shows that this inadequate risk adjustment results in underestimation of the resources required to treat beneficiaries with these conditions. 42 , 43 Treating patients with more social risk factors further increases the complexity of psychiatric visits and requires more resources for treatment, compounding the increased costs of caring for patients with mental health disorders. 17 As a result, the CMS should track the effect of the MIPS program on the Part B participation rates of psychiatrists and other clinicians who disproportionately provide care for beneficiaries with social and mental health risk factors to ensure that basic levels of access to behavioral health care are maintained.…”