Claims-based frailty index improves fairness in physician reimbursement

The addition of the claims-based frailty index to the CMS Hierarchical Condition Category to Medicare’s cost prediction model correctly predicted costs of care, especially for clinicians with a disproportionate number of patients who were frail, according to a retrospective cohort study published in Annals of Internal Medicine.

Researchers wrote that adding the claims-based frailty index to Medicare’s value-based payment model could lead to fairer reimbursement for such clinicians.

“As Medicare moves toward value-based payment, hospitals, clinicians, nursing facilities, and other entities are increasingly held accountable for beneficiaries' costs of care,” Kenton J. Johnston, PhD, assistant professor at the Health Management and Policy College for Public Health and Social Justice at Saint Louis University, and colleagues wrote.

“To make fair comparisons between entities, Medicare risk-adjusts costs using the Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) cost prediction model, which includes many clinical comorbid conditions,” they continued.

Reference: Johnston KJ, et al. Ann Intern Med. 2020;doi:10.7326/M19-3261.

Researchers also wrote that using survey data to adjust payments for Medicare programs that serve as many as 60 million patients is not plausible.

“Therefore, a need exists to determine whether claims-based measures of frailty, which are easily implementable on a national scale, can improve the CMS-HCC cost prediction model,” Johnston and colleagues added.

Researchers utilized a claims-based frailty index that uses 2006 claims data from the Medicare Current Beneficiary Survey and its association with adverse health outcomes in 2007 to ascertain the frailty status of 16,535 community-dwelling, Medicare fee-for-service beneficiaries. These beneficiaries represented 26,705 patient-years. Researchers then used regression models to ascertain annualized Medicare costs with and without the claims-based frailty index.

Johnston and colleagues found that mean unadjusted annualized Medicare costs without the claims-based frailty index were $5,724 for the 8,910 patients identified as robust (46.4% of patient-years); $12,462 for the 8,405 prefrail patients (41.6% of patient-years); $26,239 for the 2,215 mildly frail patients (9.6% of patient-years); and $44,586 for the 593 patients classified as moderately to severely frail (2.5% of patient-years). When the claims-based frailty Index was added to the CMS-HCC model, an additional $2,712 in unadjusted annualized Medicare costs was added to the prefrail patients; an additional $7,915was added to the mildly frail patients; and an additional $16,449 was added to the moderately to severely frail patients.

The researchers said that on average, the model with the frailty index resulted in more accurate predictions of costs for patients at all four frailty levels, but “observed costs remained more widely distributed than predictions from the enhanced model at all levels of frailty.” In a related editorial, Mohammad Habibullah Pulok, PhD, and Kenneth Rockwood, MD, both of the Nova Scotia Health Authority in Canada, discussed “one important consideration” before using the claims-based frailty index.

“Claims-based measures do not require additional clinical measurement at the individual level,” Pulok and Rockwood wrote. “Individual patient care does, however, benefit from an approach that routinely collects reliable data about patients’ cognition, mobility, and function, as well as the presence and attributes of their caregivers.”

They added that with the first wave of baby boomers turning 75 years old in 2021, “time is running out to stop the financial disincentive against providers who offer them care and to turn toward value-based payments that recognize what otherwise is unmeasured value.” – by Janel Miller

References:

Johnston KJ, et al. Ann Intern Med. 2020;doi:10.7326/M19-3261.

Kim DH, et al. J Gerontol A Biol Sci Med Sci. 2018;doi:10.1093/gerona/glx229.

Pulok MH, Rockwood K. Ann Intern Med. 2020;doi:10.7326/M20-0873.

Disclosures: Healio Primary Care could not confirm relevant financial disclosures at the time of publication.