NQF to study sociodemographic risk adjustment of hospital performance measures

The National Quality Forum’s (NQF) Board of Directors has approved a robust trial to measure the potential impact and implications of creating a risk factor that would adjust relevant hospital payment quality measures to take into account the challenges presented in achieving the same outcomes for patients with low socioeconomic and/or minority status as for those who are more well off economically and not minorities.

Hospitals that treat a high percentage of patients that are low income and minorities have pointed out that some quality measures that will factor into Medicare and Medicaid reimbursement are influenced by factors they cannot control. For example, patients who have less education (a socioeconomic factor) or for whom English is not their primary language (a demographic factor) may be more likely to make medication errors that could land them back in the hospital. Poor patients also may be unable to fill all their prescriptions or they may have unstable housing situations that make recovery after a hospital stay challenging. Indeed, poverty itself is a known stressor linked to behavioral health problems that can make effective post-acute care disease management very difficult.

In April, an NQF Expert Panel convened at the request of the Centers for Medicare and Medicaid Services did issue a draft report that voiced concern over the possible effect of not adjusting some payment-linked quality measures to take into account the makeup of the hospital’s patient population. If hospitals that treat mainly poor and minority patients are at a disadvantage in achieving certain quality scores and this then leads to payment cuts, the overall effect of the policy could be to deepen disparities in care quality between rich and poor patients rather than erase them.

However, the report also cautioned that the risk factor should not be applied equally to all quality measures lest it simply lower the bar for hospitals that treat the economically or demographically disadvantaged — another form of entrenching disparities. Quality measures linked to a hospital’s ability to stop hospital-acquired infections or patient falls, for example, should probably not be adjusted for patient population sociodemographic factors.

Learning more about what quality measures are impacted by patient sociodemographic factors and how big the effect may be is essential in creating a sound risk adjustment system that helps lower disparities in care quality between rich and poor patient populations instead of deepening them. Without unfairly penalizing hospitals that treat more disadvantaged patients, the system should still incentivize those hospitals to be as good or better than hospitals that treat more advantaged patients

The NQF stated that it is still developing many details, including how long the trial period will be and what the requirements for measure submission will be. It also noted that during the trial period, it may endorse certain clinically and sociodemographically adjusted measures. In addition, the NQF Board ratified a recommendation to create a new standing Disparities Committee.