High Quality Elusive for Hospitals Treating Large Numbers of the Poor

A National Quality Forum (NQF) panel commissioned to study quality and risk adjustment for socioeconomic status suggests that hospitals treating a large number of poor people face significant disadvantages in achieving the high quality necessary for payment under pay for performance.


Because Medicare and other payers either are or will be paying hospitals and physicians based on quality of care delivered to patients, those that treat a disproportionate number of people with low income and little or no education can’t meet the required measures of quality.


Key provisions of the Affordable Care Act were intended to improve care by tying Medicare payments to the performance of hospitals, doctors and other providers. For example, Medicare reduces payments to hospitals where an above-average share of patients return within a month of being treated and discharged (“readmissions”).


But the panel wrote that hospitals with large numbers of poor patients experienced unfair financial penalties because “readmissions are difficult to avoid in patients who can’t afford post-discharge medications, have no social support to help with recovery at home, have no way to get to follow-up doctor appointments or are homeless.” (“Health Law’s Pay Policy Is Skewed, Panel Finds,” New York Times, April 27, 2014; Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors, Draft Technical Report for Review, National Quality Forum Report, March 18, 2014)




NQF’s current policy recommends the adjustment of outcome measures for clinical factors, such as severity of illness and co- morbidities, recognizing that patients who are sicker and have multiple conditions have a higher likelihood of worse outcomes, regardless of the quality of care provided. Its current criteria do not allow adjusting performance measures for sociodemographic factors to avoid making disparities visible. It has claimed that this will motivate efforts to improve care for disadvantaged populations. (“NQF urges Medicare performance measures that reflect demographics,” Modern Healthcare Daily Dose, April 28, 2014)


But policymakers remained concerned about income and education disparities. As a result, NQF convened an expert panel to investigate the issue. This project is funded by HHS.


NQF Recommendations


The 26-member panel recommended the following actions, specifically directed at adjusting performance measures for sociodemographic factors: (Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors, Draft Technical Report for Review, National Quality Forum Report, March 18, 2014)


  1. Distinguishing different methods for the different purposes of measurement: sociodemographic adjustment for accountability and stratification for identifying disparities
  2. Revision of the NQF criteria related to risk adjustment to include sociodemographic factors as appropriate
  3. Guidelines for selecting risk factors to include appropriate sociodemographic adjustment
  4. Expectations for information needed when outcome measures that may be adjusted for sociodemographic factors are submitted to NQF


Additional recommendations address related issues, some of which are not currently within NQF’s scope of work:


  1. Assessing the impact of accountability applications on disadvantaged patient populations and providers serving them
  2. Identifying and collecting a standard set of sociodemographic variables for performance measurement and identifying disparities
  3. A request that NQF consider expanding its role to include guidance on implementation of performance measures for accountability
  4. A request that NQF clarify that endorsement pertains to performance measures as specified and tested for a specific patient population, data source, level of analysis and setting.


To receive a copy of the NQF report, please contact Carlin Lockee at clockee@iprotean.com


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