Skilled nursing providers who care for dual-eligible beneficiaries are being put at a disadvantage by risk models that are leaving out key pieces of information.
That’s one of the key takeaways for SNF leaders from a new analysis in this month’s Health Affairs. Experts note that providers are often held accountable for factors that go well beyond their control but that have a huge influence on healthcare outcomes and utilization.
“These models are being used to move billions of dollars around the country based on measuring people’s performance. If you don’t get them right, the programs aren’t fair,” said Karen Joynt Maddox, M.D., study co-author and an assistant professor of health management and policy at Saint Louis University.
This topic has caused a lot of controversy in hospital circles, but there is an opportunity for long-term care providers to get ahead of it, she added. “It’s like comparing a school in the suburbs to a school in the inner city and wondering why the 6-year-olds are not reading at the same level. Poverty makes a difference and if you don’t account for that, it’s not really fair.”
Their study of seven year’s worth of Medicare and Medicaid data found that dually enrolled beneficiaries had much higher levels of medical, functional, cognitive and social risk factors, and thusly had higher spending than non-duals. SNF and home costs were more than 50% greater for dual enrollees, for instance.
Authors concluded that adding these factors to cost measures improved prediction and decreased differences between the two study groups. Medicare must consider using such adjustments to improve accuracy and fairness in future payment programs, Maddox argued.
“As the post-acute community starts to get pulled into these value-based arrangements under Medicare, if the risk models aren’t improved to account for how complex duals are, it could really hurt providers,” she told McKnight’s Wednesday.
