Refining Frailty Identification in Quality Metrics: Validating the HEDIS Frailty Definition Against the Clinical Frailty Measure
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PROJECT SUMMARY/ABSTRACT The Centers for Medicare & Medicaid Services (CMS) Medicare Advantage (MA) Star Ratings, which incorporate Healthcare Effectiveness Data and Information Set (HEDIS) measures, play a critical role in assessing contract performance and reimbursement. Frailty exclusions are intended to ensure that MA contracts are not penalized for appropriately withholding cancer screening from older adults with frailty, whose health goals often prioritize quality of life and symptom management over long-term prevention. However, the current HEDIS frailty definition relies on unvalidated diagnosis and procedure codes, which may lead to misclassification of frailty status and inaccurate quality assessments. This study aims to evaluate the accuracy of the HEDIS frailty definition against standard clinical frailty assessments and assess whether replacing it with the validated claims-based frailty index (CFI) affects MA Star Ratings for cancer screening. Specific aims are (1) to determine the accuracy of the HEDIS frailty definition against the Fried Frailty Phenotype and Deficit Accumulation Frailty Index leveraging the National Health and Aging Trends Study (NHATS) linked to Medicare data; and (2) to evaluate the impact of replacing the HEDIS frailty definition with the CFI on MA Star Ratings for breast and colorectal cancer screening using a 20% random sample of MA encounter data. Differences in screening rates, MA contract rankings, and Star Rating changes will be examined when the HEDIS-based frailty exclusion and the CFI-based frailty exclusion are applied. This project is innovative because it is the first to validate the HEDIS frailty definition against established clinical frailty measures using a nationally representative survey of contemporary MA beneficiaries. By demonstrating the superiority of the CFI over the HEDIS frailty definition, this study will provide evidence-based recommendations to refine frailty exclusions in quality assessments, ensuring more accurate and equitable MA Star Ratings. This contribution is significant because findings will inform CMS policies and lay the foundation for future research on frailty-based quality metrics beyond cancer screening. This research aligns with the NIH mission to enhance healthcare quality and promote the well-being of older adults.
