The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Month: April 2017 (page 1 of 2)

Providing high quality care to Medicare beneficiaries

Brooke Kenney, MPH, is a data analyst for MVC and MSHOP.

According to the World Health Organization (WHO), social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. As key players in health inequity and outcomes these conditions have received a lot of attention lately from health care delivery systems and the U.S. government.1

Value-based payment models (VBP), which aim to apply payment to the quality and efficiency of care delivered, are, in part, a response to help address populations with SDH and to support the providers that serve these communities. However, caring for patients with social risk factors may cost more and make it harder to achieve high performance on quality metrics, thus VBP could actually promote unintended consequences, especially because some social risk factors may be outside the provider’s realm of influence.

In October 2014, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which required an evaluation of Medicare payment programs using socioeconomic status (SES) as a predictor of quality measures and resource utilization. Study A, the first installation, focuses on socioeconomic information currently available in Medicare data. The full report, released in December 2016, can be found here. The second installation or Study B, to be completed by October 2019, will expand the analyses by using non-Medicare datasets to quantify SES. The major findings and conclusions from Study A in the Report to Congress are given below.2

Scope: The social risk factors examined were dual enrollment in Medicare and Medicaid as a marker for low income, residence in a low-income area, race, Hispanic ethnicity, residence in a rural area, and disability. The scope of these social risk factors is expected to be expanded on in Study B.

Finding 1) Beneficiaries with social risk factors had worse outcomes on many quality measures, regardless of the providers they saw, and dual enrollment status was the most powerful predictor of poor outcomes.

For the most part, these findings persisted after risk adjustment, across care settings, measure types, and programs, and were moderate in size. Risk-adjusted mortality rates (from HVBP), risk-adjusted admissions for heart failure (from Medicare Shared Savings Program), and risk-adjusted inpatient readmissions of Medicare SNF beneficiaries to IPPS hospitals and critical access hospitals (from SNF VBP) were the noted exceptions.

Finding 2) Providers that disproportionately served beneficiaries with social risk factors tended to have worse performance on quality measures, even after accounting for their beneficiary mix, and incurred penalties under all five current value-based purchasing programs in which penalties are currently assessed.

As a result, safety-net providers were more likely to face financial penalties across all but one of the Medicare value-based purchasing programs. This exception was that ACOs with a high proportion of dually-enrolled beneficiaries were more likely to share in savings under the Medicare Shared Savings Program. However, in every setting there were some providers that served a high proportion of beneficiaries with social risk factors who achieved high levels of performance.

Conclusions: This study seeks to answer whether beneficiaries with social risk factors have worse outcomes due to their social risk profile, or because of the providers they see as well as whether providers serving high numbers of beneficiaries with social risk factors provide worse care overall or perform worse due to this high proportion. The conclusion is that dual enrollment status is independently associated with worse outcomes, and dually enrolled beneficiaries are more likely to see lower-quality providers. Therefore, solutions that address only social risk factors or only provider performance will be less effective at navigating the complex relationship between social risk factors and performance.

Evaluation alone cannot explain why these observed patterns exist, primarily because a host of outside factors influence patient health which are not easily measured with current data. In light of these limitations, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) have proposed 3 key strategies to enable all Medicare beneficiaries to receive the highest quality of healthcare services.

Strategy 1: Measure and report quality of care for beneficiaries with social risk factors. This will involve enhancing data collection and developing statistical techniques to allow measurement and reporting of performance on key quality and resource-use measures for such subgroups.

Strategy 2: Set high, fair quality standards for all beneficiaries. Measures should be individually examined to determine whether adjustment for social risk factors is appropriate to make them as equitable as possible. This determination will depend on the measure and its empirical relationship to social risk factors.

Strategy 3: Reward and support better outcomes for beneficiaries with social risk factors. Whereas value-based purchasing programs reward achievement of high quality and good outcomes among all beneficiaries, we should also consider creating additional targeted financial incentives to reward achievement or improvement specifically for socially at-risk beneficiaries.

1WHO: World Conference on Social Determinants of Health. Rio Political Declaration on Social Determinants of Health (2011) Retrieved from Web 10 Apr. 2017

2United States Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (2016) Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs: A Report Required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. Washington, D.C.

Questions or comments?  We’d love to hear from you!  You can comment on this article, or fill out the form at the bottom of the page.

5 ways MVC can help you develop a post-acute care strategy

Kristyn Vermeesch

Kristyn Vermeesch is the Project Manager for MVC.

As highlighted in previous blog posts, the transition to value-based purchasing has brought greater attention to post-discharge care, and how to improve its value for patients.  This is not an easy riddle to solve. A previous blog post, “Optimizing Post-Acute Care Spending: Care Setting or Intensity?”, showed improvements could be made regarding the type of post-acute care chosen for patients. An example of how to translate these findings into action is the post-acute strategy checklist developed by the Deloitte Center for Health Solutions. The checklist was developed based on recommendations from a broad interviewee list including health systems, health plans, professional organizations and post-acute care companies.  Whether by using the Deloitte checklist or another alternative, the Michigan Value Collaborative (MVC) can help hospitals develop their own personal roadmap for post-acute care success.

  1. Identification of post-acute partners: One of the biggest challenges faced by hospitals is understanding where and what additional care patients are receiving after discharge. This is especially true when patients receive post-acute care from an unaffiliated provider.

How can MVC help?  On the MVC registry, member hospitals are able to identify the skilled nursing facilities (SNFs) utilized by their patients and for what conditions.  Spoiler alert: the Coordinating Center is creating a similar report to help hospitals gain more information about their home health care partners.  For more information on how to access the SNF report, check out our YouTube videos.

  1. Building post-acute care partnerships: Understanding where patients receive care is important, but it is also critical to know which post-acute providers are delivering high-quality care. This includes scrutinizing clinical measures such as average length of stay, readmission rates, infection rates, and ED visit rates. This knowledge will help to solidify strong partnerships and help with patient referrals.

How can MVC help?  The SNF report on the MVC registry displays the total length of stay and price-standardized, risk-adjusted cost associated with each SNF utilized by your hospital.  Each SNF’s adjusted costs are a derivative of the length of stay and services provided – not payer contractual rates, which can help to assess the quality of care provided by each partner SNF.  The report also includes any readmission payment associated with the patient visit, and in the next few months, the registry will be expanding to provide greater analytic support for post-acute decision-making. More details to come at the April semi-annual meeting!

In addition to the SNF report, members may assess their performance in other downstream post-acute care components such as readmissions, ED visits, and inpatient and outpatient rehabilitation to help improve patient care.  The MVC data can not only inform hospitals on what providers perform greater high-quality care, but it may also be used to develop quality improvement initiatives both within the hospital as well as with its strategic partners. The Coordinating Center is another resource to help hospitals understand the data as well as provide customized analytics. 

  1. Decide where to begin improving performance: Identifying an opportunity is only half the equation.  The next step is deciding where to focus quality improvement efforts.   

How can MVC help?  The MVC registry allows hospitals to compare themselves to hospitals throughout the state and soon to their MVC cohort (facilities with comparable patient case mix and structural similarities).  Hospitals can evaluate which care component(s) have the greatest impact on post-acute spend and whether they have higher utilization rates of more expensive services, such as SNFs or inpatient rehab. 

  1. Develop achievable goals: Goals for hospitals and post-acute partners should be realistic and not compromise patient care.

How can MVC help?  Performance data from post-acute partners, as well as benchmarking data from other Michigan hospitals, can be used to develop achievable goals that can be tracked over time to assess progress.

  1. Implement evidence-based practices: Identifying successful initiatives and best-practices from other institutions can help hospitals implement positive change; however, identifying those opportunities can present a challenge.

How can MVC help?  In addition to data analytics, MVC provides a platform for cross-institutional learning and sharing of best practices.  MVC’s peer-to-peer virtual workgroups allow hospitals throughout the state to discuss challenges and innovative quality improvement initiatives, including strategies to reduce readmissions and inappropriate SNF utilization.  The workgroup discussions are captured in “Toolkits”, which identify root causes and best practices to address the challenges faced by many Michigan hospitals.  The Toolkits are freely available to all MVC hospitals. In addition to the workgroups, the MVC blog features articles on statewide and national initiatives as well as highlighting key research findings that may be useful to hospitals. Finally, the MVC semiannual meetings allow hospitals to learn more about how other members are addressing similar challenges, provides an opportunity to ask questions and network.

Want to learn more?  Register for our April semi-annual meeting or contact the Coordinating Center using the form at the bottom of this page.


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