The Opportunity

The quality measurement enterprise seeks to link payment to quality of care, generally known as value-based purchasing (VBP). For VBP to be successful, patients need accurate and reliable information on provider performance to make informed decisions. In addition, providers need comprehensive, reliable, and timely information to make quality care decisions that result in improved outcomes for patients while being held accountable for those outcomes in a fair and comparable manner. To level the playing field, risk adjustment methods have been applied to many measures, but not all, and not in a standardized method across measures.

Risk adjusting measures to account for differences in patient health status and clinical factors (e.g., comorbidities, severity of illness) that are present at the start of care has been widely accepted and implemented.^1,2 However, the increased use of outcome and resource use measures in payment models and public reporting programs has raised concerns regarding the adequacy and fairness of the risk adjustment methodologies used in these measures, especially as it relates to functional status and social risk factors such as income, education, social support, neighborhood deprivation and rurality.^3,4 Functional risk factors are important to examine since they may mediate the relationship between social risk, quality outcomes, and resource use. Measure developers have long expressed a need for technical guidance on developing and testing social and/or clinical risk adjustment models for endorsement and maintenance, and the appropriateness of a standardized risk adjustment framework.⁵ Moreover, risk adjustment of functional status-related factors within quality measurement is under-explored and under-utilized for comparing provider performance on health outcomes and resource use.

For this effort, NQF will build on several years of work on developing guidance for risk adjustment model development. Prior to 2015, NQF’s guidance prohibited the inclusion of social risk factors in the risk adjustment models of measures submitted for NQF review and endorsement due to concerns of masking disparities in care. NQF convened a Risk Adjustment Expert Panel in 2015, which recommended allowing risk adjustment when there is a conceptual and empirical relationship. The NQF Board of Directors then implemented a trial period in 2015 during which adjustment of measures for social risk factors was no longer prohibited. As a result of the trial period in 2017, the NQF Committees and measure developers noted the importance of addressing all factors (both clinical and social) that can influence the result and validity of a performance measure in truly reflecting care quality.⁶ However, these efforts have demonstrated that social risk adjustment may be feasible and appropriate, but it remains challenging for many measure developers. Limited availability of adequate social risk factor data and significant heterogeneity of social risk data and modeling approaches suggests that exploration of electronic data sources to support functional and social risk adjustment is a critical next step. Furthermore, quality of care for the most vulnerable may further be mediated by the relationship between social risk, quality outcomes, and functional status. Therefore, functional status-related risk adjustment should be explored within quality measurement, in addition to social risk factors.

About the Project

NQF seeks to advance measurement science in this important area by developing Technical Guidance for measure developers that includes emerging good and best practices for functional and social risk factor adjustment in measure development. The beginning of this project started with an environmental scan of data sources used for risk adjustment, functional or social risk factors available for testing, and approaches to conceptual and statistical methods for risk adjustment. This environmental scan influenced the first iteration of the Technical Guidance, as common approaches and emerging best practices were identified in the scan. This project will continue into an option period where the Technical Guidance will be socialized to a broader group of diverse stakeholders to gain feedback on its applicability, feasibility, and implications for the future of quality measure development.

NQF has assembled a Technical Expert Panel (TEP) to work towards consensus decisions. In the initial base period of the project, the TEP yielded a scholarly environmental scan report regarding the current state of data sources used for risk adjustment, functional or social risk factors available for testing, and approaches to conceptual and statistical methods for risk adjustment. The TEP used the scan to develop Technical Guidance for measure developers that includes emerging good and best practices on when and how to adjust for functional and social risk factors in measure development. In the option period, the TEP will investigate how diverse stakeholders view the Technical Guidance, especially to operationalize its recommendations.

Objectives

The TEP will:

• Provide guidance on the environmental scan of data sources and current approaches to conceptual and statistical methods for risk adjustment.
• Provide guidance on the development of a Technical Guidance report for measure developers on the process of developing a risk adjustment model considering functional and social risk factors.
• Leverage their experience and expertise to inform the broadened stakeholder engagement (i.e., focus groups) and their execution;
• Drive to consensus on updates to the Technical Guidance based on findings from the stakeholder engagement; and
• Outline a potential path forward for areas where consensus cannot be reached

NQF Process

NQF will convene a multi-stakeholder TEP over the next 24-months to provide input on the current state of risk adjustment for social and functional status in measurement, best practices for social and functional status-related risk adjustment, the appropriateness of a standard risk adjustment framework, and the development of technical guidance for measure developers.

During the initial 12-months of the project, NQF conducted an environmental scan to identify current uses of functional and social risk factors in measurement. The TEP provided input on the environmental scan, using relevant elements of the NQF’s Consensus Development process to receive and review comments. NQF and the TEP also worked to develop Technical Guidance on good and best practices for functional and social risk factor adjustment in measure development. During the next 12-months (option period), NQF will broaden it stakeholder engagement efforts to garner input on the utility of the Technical Guidance, and to make updates to the Technical Guidance based stakeholder feedback and TEP input. These processes will not involve voting or the endorsement of any product. Throughout this project, NQF will solicit input from NQF membership and public stakeholders at key points in the project.

Funding

This project is funded under NQF’s contract with the Department of Health and Human Services CMS. For information about the availability of auxiliary aids and services for NQF’s federally funded projects, please visit http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html.

Events

• Option Period Web Meeting #1 – 10/22/21
• Option Period Web Meeting #2 – 5/12/22
• Option Period Web Meeting #3 – 7/13/22
• Option Period Web Meeting #4 – 10/24/22

Related NQF Work

• Healthcare Disparities and Cultural Competency Consensus Standards: Disparities-Sensitive Measure Assessment
• Social Risk Trial Final Report
• A Roadmap for Promoting Health Equity and Eliminating Disparities: The Four I’s for Health Equity
• National Quality Partners NQP SDOH Data Integration Action Team SDOH Payment Summit (PDF)

Contact Information

For more information, please contact the project team a RAGuidance@qualityforum.org.

1. Franks P, Fiscella K. Effect of Patient Socioeconomic Status on Physician Profiles for Prevention, Disease Management, and Diagnostic Testing Costs. Medical Care 2002;40:717-24. doi:10.1097/01.mlr.0000020931.02753.72.2
2. Blum AB, Egorova NN, Sosunov EA, et al. Impact of Socioeconomic Status Measures on Hospital Profiling in New York City. Circulation: Cardiovascular Quality and Outcomes 2014;7:391-7. doi:10.1161/CIRCOUTCOMES.113.000520
3. Bernheim SM, Parzynski CS, Horwitz L, et al. Accounting for Patients’ Socioeconomic Status Does not Change Hospital Readmission Rates. Health Affairs 2016;35:1461-70. doi:10.1377/hlthaff.2015.0394.3
4. Chatterjee P, Werner RM. The Hospital Readmission Reduction Program and Social Risk. Health Services Research 2019;54:324-6. doi:10.1111/1475-6773.13131
5. National Quality Forum. Evaluation of the NQF Trial Period for Risk Adjustment for Social Risk Factors. July, 2017. https://www.qualityforum.org/Publications/2017/07/Social_Risk_Trial_Final_Report.aspx.
6. Ibid.