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FOTO Rehab Outcomes Blog

Association of Practice-Level Social and Medical Risk With Performance

Do you believe most of your patients are simple with little to no factors affecting the outcome of the care you provide? 

In a previous post I brought up the concept of social determinants of health.  A recent study looked at whether social determinants of health, medical factors or a combination of both would have an effect on incentive payments and penalties for practices.

After reading the abstract, I have an even better appreciation for what FOTO is able to do for clinicians and organizations with its risk adjustment process.  If risk is not accounted for in a value based payment model, then truly earned bonuses may not be earned OR undeserved penalties may occur.  Most of the current alternative payment models aren't really including a provision acknowledging risk adjustment or the importance of risk adjustment. Risk adjusted outcomes are key for a successful alternative payment model.

A favorable component within FOTO is a strong risk adjustment process coupled with predictive analytics. It's almost like having artificial intelligence onboard immediately at the start of an episode of care.  The next level of power within the system is analyzing data. The data revolves around the initial assessment, the predicted outcome and the final outcome. The final analysis using aggregated data determines the effectiveness and efficiency of the care provided.

If you take a look at the abstract, you'll see what can happen when a  payment model is based on raw data. The authors make a valid point that patients aren't all the same and that the payment models do not adequately address the patient risk factors.

Below you will find a quick view of the abstract.


Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program.




Medicare recently launched the Physician Value-Based Payment Modifier (PVBM) Program, a mandatory pay-for-performance program for physician practices. Little is known about performance by practices that serve socially or medically high-risk patients.


To compare performance in the PVBM Program by practice characteristics.


Cross-sectional observational study using PVBM Program data for payments made in 2015 based on performance of large US physician practices caring for fee-for-service Medicare beneficiaries in 2013.


High social risk (defined as practices in the top quartile of proportion of patients dually eligible for Medicare and Medicaid) and high medical risk (defined as practices in the top quartile of mean Hierarchical Condition Category risk score among fee-for-service beneficiaries).


Quality and cost z scores based on a composite of individual measures. Higher z scores reflect better performance on quality; lower scores, better performance on costs.


Among 899 physician practices with 5 189 880 beneficiaries, 547 practices were categorized as low risk (neither high social nor high medical risk) (mean, 7909 beneficiaries; mean, 320 clinicians), 128 were high medical risk only (mean, 3675 beneficiaries; mean, 370 clinicians), 102 were high social risk only (mean, 1635 beneficiaries; mean, 284 clinicians), and 122 were high medical and social risk (mean, 1858 beneficiaries; mean, 269 clinicians). Practices categorized as low risk performed the best on the composite quality score (z score, 0.18 [95% CI, 0.09 to 0.28]) compared with each of the practices categorized as high risk (high medical risk only: z score, -0.55 [95% CI, -0.77 to -0.32]; high social risk only: z score, -0.86 [95% CI, -1.17 to -0.54]; and high medical and social risk: -0.78 [95% CI, -1.04 to -0.51]) (P < .001 across groups). Practices categorized as high social risk only performed the best on the composite cost score (z score, -0.52 [95% CI, -0.71 to -0.33]), low risk had the next best cost score (z score, -0.18 [95% CI, -0.25 to -0.10]), then high medical and social risk (z score, 0.40 [95% CI, 0.23 to 0.57]), and then high medical risk only (z score, 0.82 [95% CI, 0.65 to 0.99]) (P < .001 across groups). Total per capita costs were $9506 for practices categorized as low risk, $13 683 for high medical risk only, $8214 for high social risk only, and $11 692 for high medical and social risk. These patterns were associated with fewer bonuses and more penalties for high-risk practices.


During the first year of the Medicare Physician Value-Based Payment Modifier Program, physician practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs.

 2017 Aug 1;318(5):453-461. doi: 10.1001/jama.2017.9643.