Johnston KJ, et al. - Researchers investigated the effect of the factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, as well as local area health resources and economic conditions, on Medicare total annual cost of care (TACC). In addition, they assessed the impact of accounting for these factors on the TACC performance by outpatient safety-net clinicians. Researchers found that Medicare beneficiaries commonly displayed neuropsychological and functional impairment, which were associated with increases in the annual Medicare spending. For the TACC of treated Medicare patients, assessing outpatient clinicians without considering other patient factors may inappropriately penalize safety-net clinicians who care for these vulnerable groups.

Methods

• Researchers performed a retrospective observational study.
• Using the Medicare Current Beneficiary Survey (MCBS), they examined patient-reported neuropsychological and functional status and, using the Area Health Resources File, they obtained information on local area characteristics.
• Medicare beneficiaries with annual physician or clinic visits to outpatient safety-net (federally qualified health centers and rural health clinics) and non–safety-net clinics were included; these contributed to 76,927 person-years of data to the MCBS from 2006 through 2013.
• They estimated the association between each factor and annual Medicare spending using patient-level multivariable regression models, and compared outpatient safety-net performance under current risk adjustment and after adding additional adjustment for these factors.
• Main outcomes and measures included Medicare TACC, measured as the total annual reimbursed amount per patient for Medicare Part A and Part B services, in all categories.

Results

• In this study, 111,414 unique identifiable physicians were included, and 213,904,324 patient-years (unweighted, 76,927 patient-years) from 30,058 unique patients, of whom 17,478 (58.1%) were women, were included in the final weighted sample.
• The patients had mean (standard deviation) patient age of 71.84 (12.48) years.
• The mean TACC was $9,117.
• Higher than mean TACC was noted for beneficiaries with depression ($14,436), dementia ($18,311), and difficulty with three or more activities of daily living (ADLs, $19,113) or instrumental ADLs ($17,443).
• After adjusting for comorbidities, depression was associated with $2,740 (95% CI: $2,200-$2,739) and dementia with $2,922 (95% CI: $2,399-$3,445) higher TACC.
• Higher TACC was also noted in correlation with difficulty with three or more ADLs ($3,121 higher; 95% CI: $2,633-$3,609) or instrumental ADLs ($895 higher; 95% CI: $452-$1,337).
• Risk adjustment calculations made with the addition of these neuropsychological and functional factors, as well as local residence area factors, led to a reduction in outpatient safety-net clinicians’ underperformance on Medicare TACC relative to non-safety–net clinicians by 52% (from 0.098 to 0.047 difference in the observed to expected ratio).