A new analysis by a team of researchers led by Dr. David Nerenz of Henry Ford’s Health System reveals that consideration of social risk factors such as poverty, housing instability and transport insecurity can have a significant impact on health quality indicators without compromising quality of care.
In a report published today on Health mattersThe researchers argue that using social risk factors in specific circumstances to “align the playing field” for the purpose of adjusting the quality metrics used for quality reporting and value-based purchasing plans. Social risk adjustment will apply to scenarios in which providers are unable to mitigate the impact of social risk factors and when these risk factors directly affect treatment outcomes.
“We acknowledge the challenges of knowing when social risk adjustment is appropriate, but we have shown when to do it and not to do it,” said David Nerenz, Ph.D., director of emeritus at the Henry Ford Center for Policy and Health Research and Services. The lead author of the study.
“In our analysis we show that compliance with social risk factors will not necessarily disguise or justify poor quality. Instead, it can demonstrate exceptional quality levels among safety net providers.”
The adjustment of quality metrics to social risk factors has been at the center of an ongoing debate over the past decade since it was proven that the Medicare Hospital Admission Reduction Program (HRRP) disproportionately punishes safety net hospitals. Safety net hospitals have long held that they are being unfairly punished because social risk factors place their patients at higher risk for readmission and are not HRRP compliant.
In 2014, a team of experts convened by the National Quality Forum recommended the use of social risk factors in certain circumstances. However, the Assistant Secretary of Planning and Evaluation, the chief adviser to the U.S. Department of Health and Human Services Secretary, released a June 2020 report opposing adjustments to social risk factors.
“It was a controversial issue, but there is a growing consensus that social risk is important,” he said.
Karen Joint Maddox, MD, MPH, Partner of Health matters Report and Assistant Professor of Medicine in the Cardiovascular Division of the School of Medicine at the University of Washington in Missouri.
“To move forward to high value-added treatment that improves the health of populations, capital needs to be central rather than a last thought. We this analysis drives the needle to make it happen.”
Dr. Nerenz and Dr. Maddox led a study published in Health Services Research In 2019 it found that a risk adjustment model including social factors may reduce the financial penalty of at least half of all hospitals in the safety net treating patients regardless of their insurance status or their ability to pay. In some cases, the study said, the fitting model could exclude them from any fine.
In contrast, more affluent hospitals — those that treat higher-educated patients — could see their punishment for repeat admission rates.
Quality metrics such as mortality rates, recurrence rates, complication rates, and mean functional improvement are used to compare physicians, hospitals, home health agencies, and health programs. These measures are then applied to determine monetary rewards and penalties for suppliers that yield relatively good or bad performance.
Because providers do not treat the same mix of patients, and some patients are at higher or lower risk of poor outcome than others, some form of statistical adjustment is applied to the level of the playing field for comparison, Dr. Nerenz said.
“While clinical risk factors such as age, the presence of other diseases and the severity of the disease are routinely used in these adjustments, social risk factors have not been such,” said Dr. Nerenz. Other than quality that is not under the control of suppliers. “