Operators serving a disproportionate share of Medicare beneficiaries for depression, dementia, frailty, and social risk factors are penalized twice, argue the authors of a recent viewpoint published in JAMA.
First, they are shortchanged by a measurement system that makes their risk-adjusted performance appear worse than it actually is. A second blow is delivered by a payment system that fails to adequately reimburse for full medical risks.
The model does not include depression or Alzheimer’s disease and related dementias (hereafter referred to as dementia), frailty, or social disadvantage in the risk points it assigns to Medicare beneficiaries.
The Centers for Medicare & Medicaid Services could address these issues by adding diagnostic codes for depression and dementia to the clinical conditions its hierarchical condition categories model, the researchers argue. Adding claims-based frailty measures and incorporating social risk into current models would also even out the playing field, they wrote.
“While it’s an unintended consequence of the current Medicare payment policy, those who are among the most vulnerable are less likely to get the care that they need,” explained Kenton Johnston, Ph.D., a professor with the Saint Louis University College for Public Health and Social Justice. “This disparity has already created an incentive for providers and plans to avoid treating Medicare beneficiaries with those conditions.”
Any concerns CMS may have regarding over-coding to increase reimbursement could be addressed through existing Medicare fraud procedures, he added.
“While fraud and abuse protections could and should be strengthened, it is unfair for CMS to penalize clinicians and health plans that care for vulnerable patients because of potential fraud that can best be handled using other more effective means that would not create inequitable reimbursement,” the authors concluded.