05 Apr Off
By George “Mike” Brett, MD
Senior Vice President of Consulting and Chief Medical Officer
In addition to demographic information and HCCs, a portion of a PACE participant’s risk score is derived from the Frailty Factor (FF). Eligible participants in PACE have the FF added to their risk score because the CMS-HCC Model uses diagnosis codes which consistently under-predict the cost of care for the frail elderly. This happens because predicting cost based on diagnosis codes alone can’t account for the added cost that results from older adults’ functional impairment as a consequence of the diagnosis.
To deal with this discrepancy, CMS attempts to evaluate functional impairment by assessing Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). CMS has contracted with DataStat to administer a questionnaire to all eligible PACE participants. The questionnaire is called the Health Outcomes Survey – Modified (HOS-M). This survey is mailed to the participant’s home in April with instructions on how it is to be completed and returned. If the participant is unable to complete it due to physical or mental incapacities, a family member or friend can assist. Based on the returned surveys, DataStat calculates the percentage of participants in each PACE program with impairment of zero, 1-2, 3-4, and 5-6 ADL’s. This is then averaged into a plan-wide FF. All eligible PACE participants in a program get the same FF. Participants considered to be “Long Term Institutional” or who are in the ESRD HCC model are not eligible.
In 2018, the average FF in PACE is 0.138 but the range is quite wide. Don’t be put off by this small number. On average (depending where the participant lives), this average FF brings an additional $1,850 of revenue annually for each eligible participant. It can be much higher or lower depending on the results of the HOS-M.
It is important for your participants to accurately complete this survey and effort should be put forth to emphasize this with participants as well as their caregivers. Left on their own, there is a tendency for elders to understate their functional impairment. Therefore, we suggest encouraging your participants to bring the surveys to the PACE center to be completed there. During the day, a designated nurse or social worker can take the participant into a quiet room and oversee the participant’s completion of the HOS-M. Be mindful that the nurse cannot tell the participant what to write, but they can certainly provide clarification and “reality checks.”
Remember, your program’s FF is only as good as the results of your previous survey.