Social Risk Adjustment Promotes Health Equity In Value Based Care

Adjusting quality measures for social risk factors can promote health equity, according to expert guidance published in Health Affairs.

As value-based payment programs expand, there is growing concern that reimbursement models could penalize providers who serve the most vulnerable populations is growing.

The experts explained that while health outcome measures reflect quality of care, they are also contingent upon factors such as personal behavior and community resources. Therefore, they argue, health outcome measures should be adjusted for these non-quality related factors when appropriate.

For instance, providers serving socially vulnerable patients might yield lower-quality care scores compared to other providers who serve more socially advantaged patients due to a lack of resources. The authors defined this as a “between-provider difference in quality.” For example, safety-net hospitals may deliver lower-quality care to patients with COVID-19 if they do not have enough ventilators or clinicians, both of which are factors out of their control.

“To the extent that the effects of social risk factors are independent of quality and unmodifiable by the entities being measured, adjustment is desirable—and even essential,” the report authors wrote. “Adjusting for social risk avoids misclassifying providers as giving poor-quality care. Such misclassification undermines the goal of informed consumer choice, unfairly penalizes safety-net providers, and actively discourages providers from serving socially at-risk communities.”

Clinical risk adjustment, like social risk adjustment, is not contingent upon quality of care. For instance, heart failure is included in clinical risk-adjustment models for heart surgery because patients with heart failure who undergo surgery have worse outcomes than patients without heart failure.

Therefore, this risk-adjustment protects providers who care for populations with high levels of heart failure from being penalized because of the make-up of the population they serve.

If a similar rationale were applied to social risks, low-income status, for example, would be included in risk-adjustment models. After all, low-income patients are more likely to be readmitted after hospital discharge compared to higher-income patients, potentially because low-income patients have less social support to assist with their care.

Housing stability is another social factor independent of quality of care that affects health outcomes, as it may be associated with hospital readmission or glycemic control for patients with diabetes.

A within-provider difference in quality is when socially disadvantaged patients receive lower-quality care compared to those socially advantaged patients. Social risk adjustments made in this scenario would mask poor-quality care. Therefore, the study authors noted, “The key question then is whether social risk factors primarily act as within-provider versus between-provider differences.”

The experts suggested that including a patient-level variable for social risk and a provider-level variable for the percentage of socially vulnerable patients in the risk-adjustment model would allow for providers to determine whether to make a social risk adjustment in a particular scenario.

“The effect size for the patient-level variable represents within-provider differences, whereas the provider-level variable represents between-provider differences,” the report authors wrote. “Adjusting for social risk will not mask systematic differences between safety-net and non-safety-net providers if the patient-level effect is large and the provider-level effect is negligible.”

If the provider-level effect is large, adjusting for social risk may mask differences in quality between safety-net and non-safety-net providers.

However, the authors concluded that even if adjusting for social risk factors masks disparities, the consequences of not making the adjustments could be even worse. Social risk adjustment makes it less likely for safety-net providers to be financially penalized, giving them more resources to care for disadvantaged patients and furthering the goal of health equity.

“Inequities in the health care system and society at large have become a stain on the United States. Taking resources away from safety-net hospitals may have the unintended effect of exacerbating disparities,” the experts wrote. “Thus, we believe that, for such measures where there are valid arguments to adjust and not adjust, the new default should be to adjust for soc