Beneficiaries with certain social risk factors—income, education, race and ethnicity, employment, community resources, and social support—have worse outcomes than other beneficiaries both because of their social risk factors and due to the providers they see. Additionally, providers who serve beneficiaries with social risk factors tend to perform worse both because of patient population and overall performance. A review conducted by the HHS Assistant Secretary for Planning and Evaluation determined that while the patterns could be attributable to multiple factors—living environments, medical risk—there are potential solutions. The ASPE report recommends adjustments to quality and resource measures as well as changes to payment methodologies as solutions to mitigate the impact of social risk factors.
Measures. The report suggests that the reporting of provider performance on quality measures could be adjusted to account for social risk factors. In other words, performance measures could factor in the differences in patient populations treated by different providers. For example, individuals with high social risk factors—dual beneficiaries—have more medically complex needs. Thus, providers treating a greater proportion of dual beneficiaries could have their performance scores adjusted to reflect that fact. Currently, the majority of process and clinical outcome measures are not adjusted to account for social risk factors. Opponents of adjusted outcome measures assert that the adjustments negatively impact transparency and mask disparities in care quality.
Payments. Additionally, the report notes that payment penalties and bonuses for performance could be based upon adjusted measures that account for social risk. While payment adjustments suffer from some of the same criticisms faced by adjustments to the measures themselves, the report notes that payment based adjustments are immune from the impacts on transparency because they take place after measure performance is reported. The report also recommended giving additional "credit" to providers with high social risk, in order to provide additional incentives to improve care and outcomes for high-risk groups.
Plan. The plan recommended by ASPE is composed of three parts: (1) measure and report on quality measures specifically for beneficiary with high social risk; (2) set high, fair, quality standards for all beneficiaries (making social risk adjustments for measures where appropriate); and (3) specifically reward and support the achievement of positive outcomes for beneficiaries with social risk factors.
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