Health care delivery and financing increasingly focus on the quality rather than quantity of care given to patients. This focus has created a move within Medicare toward value-based payments where providers are compensated based on the quality of care they deliver. That shift has sparked debate about whether the scores Medicare gives providers should be adjusted for characteristics outside of a clinician’s control, such as a patient’s age or the existence of multiple illnesses. Now, new research from the University of Minnesota School of Public Health suggests that Medicare should considering factoring in care that takes place in a rural setting when adjusting for risk.
[Photo: Dr. Carrie Henning-Smith]
“If health care quality measures are not risk-adjusted, they may put rural providers at a disadvantage in terms of scores and payment based on factors largely outside of their control. This may unfairly penalize rural providers and may also create a disincentive for new providers to locate in rural areas,” said assistant professor Dr. Carrie Henning-Smith. “On the other hand, adjusting too much may mask real — and troubling — differences in the quality of care received by patients in rural areas.”
In the two papers, Dr. Henning-Smith and her colleagues compared a range of Medicare quality measures, such as patient satisfaction, hospital readmission rates, and health outcomes between rural and urban providers. They found that in unadjusted models, rural areas demonstrated lower quality scores in most measures.
“Some of those differences were erased after adjusting for individual and community characteristics,” said Dr. Henning-Smith.
However, most of the differences in quality of care remained after accounting for individual and community factors, suggesting that something unknown is dragging down the quality scores of rural providers.
Dr. Henning-Smith said the results call for additional research to better understand what it is about rural areas, above and beyond the many socio-demographic characteristics that she adjusted for, that still accounts for differences in quality.
“We need to better understand what unique qualities of the rural environment, including patient characteristics, provider practice style, access to care, and the social determinants of health, may be accounting for the differences we find,” said Dr. Henning-Smith. “I also think that these findings call for a two-pronged reaction: first, it is important to devise risk-adjustment strategies that treat all providers fairly, regardless of where they practice and how challenging that environment might be. Secondly, and perhaps more importantly, we need to find and address the underlying cause for differences in health and health care quality by rurality.”
Dr. Henning-Smith and her colleagues with the University of Minnesota’s Rural Health Research Center are continuing to investigate this topic to better understand some of the underlying social determinants of health, including transportation and social isolation.