Adjusting payments, quality measures and programs like the hospital readmissions reduction effort for socioeconomic status of patients has been more controversial than it might seem on the surface. Some opponents feel that it amounts to admitting that it is okay if lower status patients get worse care. Providers and health plans believe not making such adjustments penalizing those who are treating higher numbers of these often more difficult to treat and higher morbidity patients. A study carried by Health Affairs suggests that at least in the case of Medicare Advantage star ratings, such adjustments would change rankings and potentially payment consequences. (HA Article) The authors looked at three quality measures–blood pressure control, diabetes control and cholesterol level control–and assessed whether taking a broad set of socioeconomic factors into account would significantly change the relative performance of MA plans. Demographic and socioeconomic variables included sex, age, dual eligibility, disability, neighborhood disadvantage (a proxy for income level) and rural/urban location. In 2012, 62% of MA enrollees included in the study had controlled blood pressure, 79% had controlled diabetes and 61% had controlled cholesterol. Compared to these group with a controlled disease status, those with uncontrolled conditions were more likely to be African-American, poor, disabled, living in a rural area or dually eligible.
Adjusting for the tested factors raised scores 2.1 percentage points for blood pressure, 4.1% for diabetes and 4.2% for cholesterol. If MA plans were divided into quintiles for scores on quality measures, the socioeconomic adjustment would significantly shift rankings for each of the quality measures. Those plans that rose in the rankings had more of the most disadvantaged members. Those that declined had fewer. Since these quintile rankings are tied to payment bonuses, this is very meaningful to plans. And getting paid more means that plans with more disadvantaged enrollees have more resources to focus on improving health. For 2017, CMS took a minor step of adding an adjustment for the proportion of dual eligibles and disabled beneficiaries served by an MA plan, but that likely doesn’t fix the broader issue. The Health Affairs and other research suggests it is pretty obvious that more needs to be done to level the playing field on quality and payment methods by ensuring that socioeconomic factors are more fully taken into account.