Understanding the social risk factor adjustment's effect on Star Ratings.

OBJECTIVES: CMS implemented the Categorical Adjustment Index (CAI) to address measurement bias in the Medicare Advantage (MA) Star Ratings, as unadjusted scores may disadvantage MA contracts serving more enrollees at greater social risk. CAI values are added to a contract's Star Ratings to adjust for the mean within-contract performance disparity associated with its percentage of enrollees with low socioeconomic status (ie, receipt of a Part D low-income subsidy or dual eligibility for Medicare and Medicaid [LIS/DE]) and who are disabled. We examined the CAI's effect on Star Ratings and the type of contracts affected. STUDY DESIGN: Observational study of MA contracts with health and prescription drug coverage. METHODS: We compared adjusted and unadjusted 2017-2020 Star Ratings overall and by contracts' proportion of LIS/DE and disabled enrollees. We assessed the CAI's effect on qualifying for quality bonus payments (QBPs), eligibility for rebate payments, and high-performing and low-performing designations. RESULTS: The CAI's impact was modest overall (3.2%-14.9% of contracts experienced one-half Star Rating changes). Upward changes were concentrated among contracts with high percentages of LIS/DE or disabled enrollees (7.7%-32.3% of these contracts saw increased Star Ratings). In 2020, 26.0% of contracts with a high proportion of LIS/DE or disabled enrollees that qualified for a QBP did so because of the CAI. CONCLUSIONS: The CAI primarily affected contracts with high LIS/DE or disabled enrollment, which received higher Star Ratings because of the CAI. The adjustment helps ensure that such contracts' performance is not understated and reduces incentives for MA contracts to avoid patients at greater social risk.

Adjusting for Patient Characteristics to Compare Quality of Care Provided by Serious Illness Programs.

Background: To compare serious illness programs (SIPs) using recently developed patient experience measures, adjustment must be made for patient characteristics not under control of the programs. Objectives: To develop a case-mix adjustment model to enable fair comparison of patient experience between SIPs by investigating the roles of patient characteristics, proxy response, and mode of survey administration (mail-only vs. mail with telephone follow-up) in survey responses. Methods: Using survey data from 2263 patients from 32 home-based SIPs across the United States, we fit regression models to assess the association between patient-level variables and scores for seven quality measures (Communication, Care Coordination, Help for Symptoms, Planning for Care, Support for Family and Friends, and two global assessments of care). Characteristics that are not consequences of the care the program delivered were considered as adjustors. Results: Final recommended case-mix adjustors are age, education, primary diagnosis, self-reported functional status, self-rated physical health, self-rated mental health, proxy respondent use, and response percentile (a measure of how soon a person responded compared with others in the same program and mode). Age, primary diagnosis, self-rated mental health, and proxy respondent use had the most impact on program-level scores. We also recommend adjusting for mode of survey administration. We find that up to 12 percent of pairs of programs would have their rankings reversed by adjustment. Conclusions: To ensure fair comparison of programs, scores should be case-mix adjusted for variables that influence patients' reports about care quality, but are not under the control of the program administering care.

Quality of Care for Youth Hospitalized for Suicidal Ideation and Self-Harm.

OBJECTIVE: To examine performance on quality measures for pediatric inpatient suicidal ideation/self-harm care, and whether performance is associated with reutilization. METHODS: Retrospective observational 8 hospital study of patients [N = 1090] aged 5 to 17 years hospitalized for suicidal ideation/self-harm between 9/1/14 and 8/31/16. Two medical records-based quality measures assessing suicidal ideation/self-harm care were evaluated, one on counseling caregivers regarding restricting access to lethal means and the other on communication between inpatient and outpatient providers regarding the follow-up plan. Multivariable logistic regression assessed associations between quality measure scores and 1) hospital site, 2) patient demographics, and 3) 30-day emergency department return visits and inpatient readmissions. RESULTS: Medical record documentation revealed that, depending on hospital site, 17% to 98% of caregivers received lethal means restriction counseling (mean 70%); inpatient-to-outpatient provider communication was documented in 0% to 51% of cases (mean 16%). The odds of documenting receipt of lethal means restriction counseling was higher for caregivers of female patients compared to caregivers of male patients (adjusted odds ratio [aOR] 1.51, 95% confidence interval [CI], 1.07-2.14). The odds of documenting inpatient-to-outpatient provider follow-up plan communication was lower for Black patients compared to White patients (aOR 0.45, 95% CI, 0.24-0.84). All-cause 30-day readmission was lower for patients with documented caregiver receipt of lethal means restriction counseling (aOR 0.48, 95% CI, 0.28-0.83). CONCLUSIONS: This study revealed disparities and deficits in the quality of care received by youth with suicidal ideation/self-harm. Providing caregivers lethal means restriction counseling prior to discharge may help to prevent readmission.

Nursing Home Responses to Performance-based Accountability: Results of a National Survey.

OBJECTIVES: The Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative aims to improve quality through performance measurement. We describe quality improvement (QI) changes that skilled nursing facilities (SNFs) reported making in response to CMS performance measurements and whether reported QI changes were associated with better performance on CMS performance measures. DESIGN: Nationally representative survey. SETTING: A total of 15,475 SNFs that reported quality performance on Nursing Home Compare in 2016. PARTICIPANTS: A total of 1,182 SNFs (58% of random sample of 2,045 SNFs). MEASUREMENTS: Adoption of 22 possible QI changes, grouped into seven categories (organizational culture, health information technology, care process redesign, provider incentives, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance); performance on the CMS Nursing Home Compare Five-Star Quality Rating System's quality measure rating. RESULTS: SNFs reported making an average of 13 QI changes (interquartile range = 11-16 changes). SNFs mostly commonly reported becoming a learning organization (87%) and providing training to staff on QI strategies (87%). After controlling for patient and facility characteristics, larger SNFs were more likely to obtain assistance on measure reporting from QI organizations and use provider champions than smaller SNFs by 14 and 11 percentage points, respectively. Rural SNFs and SNFs with higher proportions of disabled, black, or Hispanic residents adopted QI changes at similar rates as other SNFs. Of the 22 QI changes, 20 were considered at least somewhat helpful by more than 80% of adopting SNFs. Implementation of all 22 QI changes (vs no changes) was associated with a .48-star higher quality measure rating (95% confidence interval = .003-.98 stars; P = .05). CONCLUSION: In response to CMS measurement programs, SNFs reported making substantial QI investments that were associated with better performance on CMS quality measures. To guide future SNF investments in QI, work is needed to identify the QI changes that yield the greatest performance improvements.

Gynecologic radiation oncology patients report unmet needs regarding sexual health communication with providers.

PURPOSE: Following radiation therapy (RT), women with gynecologic malignancies report high rates of sexual dysfunction, but little is known regarding sexual health communication between these patients and health-care providers. This study assessed these patients' beliefs/attitudes toward providers' sexual history taking. METHODS: Surveys were administered to women who presented for follow-up care for gynecologic cancers in an academic radiation oncology department. The surveys assessed patient sexual health beliefs and inquiry preferences. Sexual functioning was assessed using the Female Sexual Function Index (FSFI). Ordered logistic regressions were performed to assess for correlations between survey responses, FSFI, and demographic characteristics. RESULTS: Seventy-five subjects participated. Most (89.8%) had FSFI scores indicating sexual dysfunction. Most patients agreed that sexual function is an important component of overall health (78.7%) and that providers should inquire regularly (62.8%). Few (12.0%) reported embarrassment around provider discussions. Most (62.7%) preferred discussion with female providers, especially married patients (p = 0.03). Half (53.4%) agreed that sexual problems are an unavoidable part of aging, a view that was more common as education level decreased (p = 0.01). Most (62.7%) patients agreed that providers should regularly ask about their sexual history, with patients having significant differences in education level. Patients with low FSFI scores were less likely to report inquiry from their OB/Gyn (p = 0.03). CONCLUSIONS: Gynecologic cancer radiotherapy patients want to discuss sexual health, but report suboptimal provider inquiry. Patient views and experiences varied based on marital status, education level, and FSFI score. This work highlights the need for improved sexual health communication between cancer patients and providers.

Adjusting Medicare Advantage star ratings for socioeconomic status and disability.

OBJECTIVES: Studies have identified potential unintended effects of not adjusting clinical performance measures in value-based purchasing programs for socioeconomic status (SES) factors. We examine the impact of SES and disability adjustments on Medicare Advantage (MA) plans' and prescription drug plans' (PDPs') contract star ratings. These analyses informed the development of the Categorical Adjustment Index (CAI), which CMS implemented with the 2017 star ratings. STUDY DESIGN: Retrospective analyses of MA and PDP performance using 2012 Medicare beneficiary-level characteristics and performance data from the Star Rating Program. METHODS: We modeled within-contract associations of beneficiary SES (Medicaid and Medicare dual eligibility [DE] or receipt of a low-income subsidy [LIS]) and disability with performance on 16 clinical measures. We estimated variability in contract-level DE/LIS and disability disparities using mixed-effects regression models. We simulated the impact of applying the CAI to adjust star ratings for DE/LIS and disability to construct the 2017 star ratings. RESULTS: DE/LIS was negatively associated with performance for 12 of 16 measures and positively associated for 2 of 16 measures. Disability was negatively associated with performance for 11 of 15 measures and positively associated for 3 of 15 measures. Adjusting star ratings using the CAI resulted in half-star rating increases for 8.5% of MA and 33.3% of PDP contracts that exceeded 50% DE/LIS beneficiaries. CONCLUSIONS: Increases in star ratings following adjustment of clinical performance for SES and disability using the CAI focused on contracts with higher percentages of DE/LIS beneficiaries. Adjustment for enrollee characteristics may improve the accuracy of quality measurement and remove incentives for providers to avoid caring for more challenging patient populations.

Effects of Caregiver and Decedent Characteristics on CAHPS Hospice Survey Scores.

CONTEXT: The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey assesses the care experiences of hospice patients and their families. Public reporting of hospice performance on these survey measures began in February 2018. OBJECTIVES: Develop an appropriate case-mix adjustment (CMA) model to allow for fair comparisons between hospices. METHODS: We analyzed CAHPS Hospice Survey data reflecting experiences of 915,442 patients who received care from 2513 hospice programs between April 2015 and March 2016. Decedent and caregiver characteristics were identified for inclusion in CMA based on their variation across hospices (as measured by intraclass correlation coefficients [ICCs]) and how predictive they were of responses to survey questions (as assessed by linear regression). RESULTS: The final CMA model included decedent age, payer for hospice care, primary diagnosis, length of final episode of hospice care, caregiver age, caregiver education, relationship to decedent, survey language/language spoken at home, and response percentile. The characteristics that varied most across hospices were language (ICC = 0.48 for Spanish survey or home language) and payer for hospice care (ICC = 0.42 for Medicare only; ICC = 0.35 for Medicare and private insurance). The characteristics that were most predictive of caregivers' survey responses were payer for hospice care, caregiver education, and survey language/language spoken at home. Lack of appropriate adjustment would incorrectly rank hospices by 1.2-5.4 percentile points. CONCLUSION: To ensure fair comparisons across hospices, CAHPS Hospice Survey measure scores should be adjusted for several caregiver and decedent characteristics.