Association Between Patient Cognitive and Functional Status and Medicare Total Annual Cost of Care

Abstract

IMPORTANCE Medicare is moving toward value-based payment. The Merit-Based Incentive Payment System (MIPS) program judges outpatient clinicians' performance on a measure of annual Medicare spending. However, this measure may disadvantage outpatient clinicians who care for vulnerable populations because the algorithm omits meaningful determinants of cost. OBJECTIVES To determine whether factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, as well as local area health resources and economic conditions, are associated with Medicare total annual cost of care (TACC), and evaluate whether accounting for these factors is associated with improved TACC performance by outpatient safety-net clinicians. DESIGN, SETTING, AND PARTICIPANTS In this retrospective observational study, we used the Medicare Current Beneficiary Survey (MCBS) to examine patient-reported neuropsychological and functional status and the Area Health Resources File to obtain information on local area characteristics. Included were Medicare beneficiaries with annual physician or clinic visits to outpatient safety-net (federally qualified health centers and rural health clinics) and non-safety-net clinics, contributing 76 927 person-years of data to the MCBS from 2006 through 2013. We used patient-level multivariable regression models to estimate the association between each factor and annual Medicare spending, and compared outpatient safety-net performance under current risk adjustment and after adding additional adjustment for these factors. MAIN OUTCOMES AND MEASURES Medicare TACC, measured as the total annual reimbursed amount per patient for Medicare Part A and Part B services, in all categories. RESULTS Our study included 111 414 unique identifiable physicians, and the final weighted sample included 213 904 324 patient-years (unweighted, 76 927 patient-years) from 30 058 unique patients, of whom 17 478 (58.1%) were women. The mean (SD) patient age was 71.84

Performance and Penalties in Year 1 of the Skilled Nursing Facility Value‐Based Purchasing Program

“…[12][13][14][15][16][17][18] Another important issue to consider in patient outcomes from SNFs is patient medical complexity, including functional status and frailty, factors that may be incompletely accounted for in risk-adjustment models currently in use. [19][20][21][22] As the SNF VBP program is new, there are no prior studies, to our knowledge, quantifying relationships between these structural characteristics and performance under the program, though one recent publication noted that facilities with a high proportion of racial and ethnic minorities or individuals living in poverty were more likely to be penalized. 23 However, prior work has suggested that structural and patient case mix characteristics are significant predictors of provider performance in VBP programs in other care settings.…”

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures

“…Frailty, which was a powerful predictor of outcomes in our study, is emerging as a key concept in risk prediction across clinical and policy applications. While risk adjustment models have historically selected adjusters that are related to the clinical question at hand (eg, using the presence of heart failure to risk adjust outcomes for heart attacks), mounting research suggests that frailty and functional status are stronger predictors of outcomes than individual comorbidities . We used a recently validated claims‐based index of frailty, and found it to be highly correlated with costs and hospitalizations; one particular strength of this approach to assessing frailty is that it can be easily implemented using claims data.…”

State variation in the characteristics of Medicare‐Medicaid dual enrollees: Implications for risk adjustment

“…While the CMS‐HCC score is calculated from disease indicators on Medicare claims in the past year, the MCBS asks about individuals' cumulative disease history. A large literature shows that functional limitations, comorbidities (including disease history), and self‐rated health exhibit strong relationships with readmissions, mortality, spending, and other outcomes commonly assessed in pay‐for‐performance programs . In addition, risk factors such as hearing and vision impairment may be precipitated by declines in health status and increase individuals' health care needs…”