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Revamping Patient-Reported Outcomes for Medicare Advantage Plans

A GAO report found that patient-reported outcomes (PRO) data is more effective for calculating Medicare Advantage risk adjustment payments.

patient-reported outcomes data

Source: Thinkstock

By Sara Heath

- Using patient-reported outcomes (PRO) data could be a better measure for risk adjustment payments for Medicare Advantage plans, but better strategies for collecting PRO data must first be developed, according to a recent report from the Government Accountability Office (GAO).

Patient-reported outcomes measures (PROMs) are indicators of functional status that the patient gives to their medical providers. Common PROMs include ability to carry groceries into a patient’s home, ability to button one’s shirt, or the ability to walk one city block. These measures look beyond a patient’s clinical status and instead at how a patient is able to live her life with certain medical issues.

PROMs, which look at functional status, may be better measures to inform risk adjustment payments for Medicare Advantage plans. CMS pays Medicare Advantage plans a risk adjustment payment to account for patients who are sicker and utilize the healthcare system more often than patients who are relatively healthier.

Currently, CMS calculates risk adjustment payments using beneficiary demographic information and clinical status, as well as some data about beneficiary frailty. In doing so, however, CMS has issued payments that are not always helpful to Medicare Advantage plans.

GAO analyzed a sample set of Medicare Advantage beneficiaries based on the risk adjustment payments they yield and their patient-reported functional statuses. On the whole, GAO found that CMS underestimated risk adjustment payments for patients with lower functional status and overestimated payments for patients with higher functional status.

READ MORE: Using Patient-Reported Outcomes Measures to Improve Engagement

The variation between risk adjustments informed by PROMs versus those traditionally calculated was different for certain conditions. For example, risk adjustment accuracy was different for patients who were unable to walk compared to patients who are unable to use the toilet, GAO reported.

Those variations notwithstanding, GAO asserted that PROMs and functional status is a better indicator of risk adjustment payments.

“Risk adjustment accuracy could be improved by accounting for functional status, thereby reducing financial disadvantages that may exist for MA plans that enroll and care for beneficiaries with functional limitations,” GAO explained. “However, the extent of improvement that could result from accounting for functional status would depend on factors such as how functional status is measured, as well as how data are collected and incorporated into the model.”

However, the medical industry has not yet determined an efficient and effective way for health plans and providers to collect PROMs, putting a wrench in GAO’s recommendations for implementing PROMs, the GAO stated.

Currently, CMS collects PROMs from about one-quarter of Medicare Advantage beneficiaries. The agency does this in post-acute care settings, outpatient therapy settings, and through patient surveys. But as noted above, PROM collection is not widespread and the methodology is not perfect.

READ MORE: AHRQ Hosts Contest for Patient-Reported Outcomes Measures Apps

For example, the mode for PROMs collection varies, GAO found. Different plans use different surveys, look at different PROMs data points, and collect PROMs at different frequencies.

Additionally, incorporating functional status data into risk adjustment calculations would impact all stakeholders.

The endeavor would be resource-intensive for CMS, requiring the agency to overhaul all of its methodologies, develop a standard set of PROMs, and develop rollout strategies. Reaching consensus in each of these areas could prove difficult, GAO said, and would be time- and labor-intensive.

For Medicare Advantage plans, which would be heavily involved in the data collection process, concerns arise about resources, as well.

“The provider and plan groups we spoke with generally expressed concern about any data collection efforts that would go beyond what CMS currently requires, and provider groups stated that they already may conduct one or more assessments of a given beneficiary,” GAO said.

READ MORE: Overcoming the Top Patient-Reported Outcomes Measures Challenges

“One group noted that it could be difficult to achieve buy-in from providers in other settings to expand those efforts given their resource-intensive nature,” the agency added.

The process of PROMs collection could also raise some flags for patients, GAO found. Beneficiaries already answering PROMs surveys could experience “assessment fatigue,” while others could be confused why they are being asked these questions. Due to the sensitive nature of functional status, some beneficiaries might consider PROMs collection an invasion of privacy.

CMS could expand the frailty section of the current risk adjustment calculation. However, survey data in this area may not be accurate or complete, posing other challenges.

GAO did not leave CMS with any concrete recommendations, but rather food for thought regarding strategies for improving the accuracy of risk adjustment payments and improving PROMs collection.

CMS is currently facing the same issues with which the rest of the industry is grappling. Patient-reported outcomes measures are hailed as essential for understanding not just the quality of care, but the results and patient experience of the care delivered.

However, very few providers actually collect PROMs, foremost because there is no concrete method for doing so. As of 2016, only about one-fifth of providers were collecting PROMs to understanding patient outcomes, according to a Health Catalyst survey. Seventy-two percent of survey respondents said they are working on mechanisms to collect and utilize PROMs.

Thirty-six percent of respondents said limited time and financial resources were big obstacles in the way of implementing PROMs collection. Twenty-six percent said they struggled to incorporate the data into their workflows, 15 percent cited technology issues, 10 percent said organizational resistance limited their efforts, and 4 percent said there was limited leadership buy-in for PROMs collection.

As the healthcare industry continues to focus not only on patient care management but the outcomes and experience of treatment, they may consider the use of PROMs in patient care. Energy must be focused on data collection and standardization, experts explain.

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