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

Abstract

See related editorial by Reuben et al. in this issue.OBJECTIVES: Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures. DESIGN: A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors. SETTING: Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey. PARTICIPANTS: Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data. MEASUREMENTS: Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression. RESULTS: Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrentyear risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00). CONCLUSION: Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.

Paying for Performance Improvement in Quality and Outcomes of Cardiovascular Care: Challenges and Prospects

“…[24][25][26] A number of recent studies have also shown that claims data can be used to detect more complex comorbidity states (eg, frailty), which holds significant promise for improving risk adjustment. [27][28][29][30][31] The advent of codes for social determinants of health in the International Classification of Diseases-Tenth Edition (ICD-10) also may provide an opportunity to collect this information more broadly than in the past and incorporate these parameters into risk prediction. 32…”

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

“… 12 Questions have also been raised about the adequacy of risk adjustment for the different patient populations seen by different types of specialists. 13 …”

“…12 Questions have also been raised about the adequacy of risk adjustment for the different patient populations seen by different types of specialists. 13 Psychiatrists represent one group for whom MIPS may be particularly poorly suited to adequately assess care quality. Concerns have been raised that there are relatively few well-defined and widely accepted behavioral health quality measures compared with other medical fields.…”

“…Furthermore, even for specialties for which specific measures have been developed, these measures may not be usable given the CMS’s plans to phase out measures with broadly high performance . Questions have also been raised about the adequacy of risk adjustment for the different patient populations seen by different types of specialists …”

Practicing Geriatrics: Mission Impossible?

“…However, geriatricians generate less revenue than generalists who care for patients with better payer mixes and can see younger patients in less time. In this issue of the Journal of the American Geriatrics Society , Johnston et al examine the case mix of geriatricians and excess costs of caring for older persons who are frail or have the common geriatrics condition of Alzheimer disease or depression . They interpret these analyses in the context of Medicareʼs Merit‐Based Incentive Payment System (MIPS) value‐based program, which in 2020 will include performance on costs, which will contribute 20% to the formula that determines whether a physician receives a bonus or financial penalty.…”