In April’s Health Affairs, Nerenz et al., note that of lack of consensus around social risk adjustment of quality measures is becoming a concern, given the expansion of CMS’s Quality Payment Program. The inclusion of individual physicians and physician groups and other clinicians in value-based payment has raised awareness about potential biases against safety-net providers, who typically have the fewest resources, serve the most vulnerable populations, and are most likely to be penalized without appropriate risk adjustment.
The main argument against social risk adjustment contends that at-risk patients may receive lower-quality care (in general) and that adjustments may mask those disparities, as noted in a recent ASPE report. In response, the authors pose five questions to consider regarding social risk adjustment for a given measure:
- Does the effect of a social risk factor reflect quality?
- Is the risk factor under the control of entities being measured?
- Are the necessary data elements available?
- Does adjustment make a difference?
- Would adjustment mask poor quality of care?
Ultimately, they determine that the key element to consider is whether risk factors primarily drive within-provider differences (those between types of patients served by the same provider) rather than between-provider differences (those between types of patients served across different providers), concluding that that social risk adjustment is an important way to avoid exacerbating health system inequity.