Adding a measure of patient frailty to Medicare payment model could lead to fairer reimbursement for clinicians

April 06, 2020

1. Adding a measure of patient frailty to Medicare payment model could lead to fairer reimbursement for clinicians
URL goes live when the embargo lifts

Researchers identified a way to measure frailty using patients' medical claims that more accurately predicts costs-of-care, especially for clinicians with disproportionate shares of frail patients. Adding this measure to Medicare's value-based payment models could lead to fairer reimbursement for clinicians who care for patients with greater needs. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Medicare currently does not adjust for patient frailty in its value-based payment models that reward Medicare clinicians for keeping patient costs-of-care low despite the fact that frail patients are known to have more complex needs and cost more to care for. This means that clinicians who care for a disproportionate share of frail patients, such as geriatricians, may be unfairly financially penalized for caring for vulnerable frail patients.

Researchers from the College for Public Health and Social Justice at Saint Louis University, as well as the Washington University School of Medicine and the Harvard University School of Medicine, used the annual Medicare Current Beneficiary Survey (MCBS) linked to respondents' fee-for-service (FFS) Medicare claims and administrative data for 2006 to 2013 to determine whether adding a claims-based frailty index (CFI) measure could improve Medicare cost prediction. They found that incorporating CFI data into cost prediction for annualized Medicare costs (AMCs) improved on the standard Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) model on average, especially among frail and dually enrolled Medicare beneficiaries. Using this data for reimbursement decisions could improve the accuracy, fairness, and equity of current methods. However, the authors caution that because individual-level cost prediction remains poor under even the augmented models, ongoing advancements in methodology are needed.

The authors of an accompanying editorial from Dalhousie University and Nova Scotia Health Authority support the authors' suggestion that providing care to vulnerable populations and being compensated fairly for it is a matter of equity. Discouraging providers could negatively affect vulnerable groups, thereby worsening health equity. Because incorporation of the CFI improved model performance in predicting cost, value-based payment models could reward providers, nonarbitrary, for rendering services to frail patients.

Media contacts: For an embargoed PDF please contact Lauren Evans at To speak with the lead author, Kenton Johnston, MD, please contact Carrie Bebermeyer at

2. Overlapping buprenorphine therapy could help patients reduce opioid use without significant withdrawal symptoms
URL goes live when the embargo lifts

Researchers from Yale School of Medicine have observed that overlapping buprenorphine therapy with long-term opioid therapy may help to avoid significant symptoms of opioid withdrawal in outpatients without opioid use disorder. A case series report is published in Annals of Internal Medicine.

Buprenorphine is a well-established treatment of opioid use disorder and is now being prescribed for patients who need to reduce opioid use but may not meet the diagnostic criteria for an opioid disorder. However, guidelines from the U.S. Department of Health and Human Services recommend cessation of full agonist opioids before buprenorphine therapy can be initiated, which induces significant enough withdrawal symptoms that patients may be unwilling to try it.

Clinicians at Yale School of Medicine developed a novel approach to initiating buprenorphine therapy that proved effective for patients at their clinic without inducing significant withdrawal symptoms. They first tried the protocol on a 62-year-old man whose regimen of controlled-release oxycodone was ineffective for his back pain and impaired his mental acuity. Attempts to lower the dose were unsuccessful because he had significant insomnia. The clinicians designed a protocol where buprenorphine was overlapped with the patient's opioid therapy for 4 to 5 days. The patient continued his therapy at home and on day 5 of the protocol, the patient did not report opioid withdrawal symptoms. On day 7, he noted night sweats and mild anxiety, prompting an increase in the buprenorphine dose. At 1 month, he reported feeling "overall better, clearer" with unchanged pain intensity but improved work performance. The experience was successful enough for the clinicians to consider this protocol for all patients referred to their clinic. They report that to date, all patients opting for this method have done so successfully, without opioid withdrawal symptoms.

Media contacts: For an embargoed PDF please contact Lauren Evans at To speak with the lead author, William C. Becker, MD, please contact Brita Belli at

Also new in this issue:

Michael T. McDermott, MD
In the Clinic

Should You Treat This Acutely Ill Medical Inpatient With Venous Thromboembolism Chemoprophylaxis? Grand Rounds Discussion from Beth Israel Deaconess Medical Center
Zahir Kanjee, MD, MPH; Kenneth A. Bauer, MD; Anthony C. Breu, MD; and Risa Burns, MD, MPH
Beyond the Guidelines

American College of Physicians

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