Social Risk Adjustment in Healthcare Performance Measures

Social Risk Adjustment in Healthcare Performance Measures

Risk adjustment is a statistical technique to generate performance measure scores by identifying and controlling patient related variables.

The terms "risk-adjusted" and "risk-standardized" are commonly used in the titles of the Centers for Medicare & Medicaid Services (CMS) outcome measures. Apart from mortality, the readmissions and complications are two widely risk-adjusted measure outcomes.

The goal of Risk Adjustment Solutions is to compare healthcare provider or hospital performance accurately. Accounting for the diagnostic complexity of patients with multiple chronic diseases, and individual choices for care, poses a significant barrier for performance measurement. It has significant implications for risk adjustment.

Individuals seeking care use the measure scores to make informed decisions such as purchasers who pay for care, including incentives or penalties; or organizations dealing healthcare services.

Social Risk Adjustment The outcome or process measures should be risk-adjusted for socioeconomic status at the individual level. It is generally accepted to risk-adjust outcome performance measures to adjust variations in patient

’s condition and clinical variables such as multiple medical conditions, and severity of disease, existing at the start of treatment. The concept of social risk adjustment depends on the impact of social risk factors on healthcare outcomes including the cost.

Social risk factors such as income, education, white-collar profession, dual-eligible profile, residential instability, and neighborhood features are all linked to health outcomes including readmissions and mortality. The effects of these variables remain statistically significant in evaluation.

The research studies have shown that risk adjusting for social variables lowers the difference in penalty amounts between safety-net and nonsafety-net assessed entities.

To evaluate the validity of Sociodemographic Status (SDS) adjustment, each performance measure is evaluated independently.

Is Social Risk Adjustment Distorting Disparities?

According to the National Quality Forum (NQF) 2014 report, disparities in performance scores between measured entity units are a reflection of variations within and between-units. Within-unit variations relate to differences between patients of various socioeconomic classes served in the same unit (hospital or physician’s clinic). Between-unit variations allude to differences between patients treated by various hospitals or clinicians irrespective of their same clinical and socioeconomic features.

The NQF report cited that there is no relationship between social risk adjustment at the individual level and the measurable performance scores. As a result, risk adjustment for social variables at the individual level would not distort healthcare disparities when comparing measured entity performance.

The 21st Century Cures Act The 21st Century Cures Act was enacted by Congress in 2016. It directed the Centers for Medicare & Medicaid Services to measure hospitals' performance in comparison to peer entities with similar numbers of patients dually eligible for Medicare and Medicaid under the Hospital Readmissions Reduction Program (HRRP) for risk adjustment.