NQF Offers Guidance for Risk Adjusting Social and Functional Risk Factors in Healthcare Quality Measurement 

DEC 21, 2022

CONTACT: Zachary Brousseau

NQF Offers Guidance for Risk Adjusting Social and Functional Risk Factors in Healthcare Quality Measurement
New Technical Guidance provides needed resource for advancing health equity

Washington, DC – The National Quality Forum (NQF) has released Technical Guidance for developing risk adjustment models to facilitate unbiased healthcare quality measurement and to advance health equity. Funded by and developed in partnership with the Centers for Medicare & Medicaid Services (CMS), the Guidance provides a standard process that reflects best practices for, and addresses methodological trade-offs of, adjustment for social and functional risk factors within quality measurement.

Risk adjustment is a statistical method that can be applied to certain types of healthcare quality measures to account for different characteristics that put some patients at greater risk of worse health outcomes. Using risk adjustment to account for differences in clinical factors, such as severity of illness or other health conditions, is widely accepted and widely implemented in quality measurement to ensure fair comparisons across providers. However, adjusting for social factors, like income or education, and functional risk factors, such as the ability to perform activities of daily living, is not yet standard practice and merits careful consideration.

There is broad agreement that quality measurement must support efforts to improve health equity and that measures should not be biased. Yet, the root causes of inequities that affect health outcomes are multiple and often interrelated, and the question of whether and how to use risk adjustment to account for social and functional risk is a matter of significant debate.

Both proponents and critics of adjusting for social risk factors point to concerns about possible unintended consequences. Those who favor adjustment note that failure to account for social risk factors in performance metrics can result in lower scores for providers that care for populations with high social risk and might, therefore, cause them to avoid caring for these populations. On the other hand, opponents argue that adjusting measures obscures true disparities in care and fails to promote further investment in achieving health equity.

“The Technical Expert Panel that developed the guidance released today grappled with differing perspectives, strongly held in some cases, and achieved consensus on a set of emerging and established best practices for developing and testing models accounting for social risk,” said Dana Gelb Safran, President & CEO, NQF. “There are a range of viewpoints on how to adjust measures to account for social and functional factors. Rather than offer a one-size-fits-all approach, this guidance gives measure developers a consistent method for designing their own models. It helps them consider the strengths, limitations, and methodological trade-offs inherent in risk adjustment, which is essential to developing better measures that draw fair comparisons.”

The Technical Guidance addresses a longstanding need for standardization and transparency by providing a step-by-step process for developing and testing risk models that consider social and functional risk. As the shift to value-based payment (VBP) programs closely linking payment to quality has taken hold, it has highlighted the importance of understanding and accounting for the impact social factors have on healthcare quality assessments.

The Guidance is the result of a two-year effort. In the first year, NQF conducted an environmental scan, convened a Technical Expert Panel (TEP), and solicited public input to produce the initial draft guidance. During this second year, the draft guidance was vetted through a series of focus groups that included representatives from patient groups, clinicians, public and private health system administrators, risk adjustment methodologists, and NQF-convened measure evaluation Committees. With keen attention to divergent perspectives, NQF placed particular emphasis on gathering feedback from stakeholders with contrasting viewpoints to the Guidance and from historically, medically underserved communities.

Based on the input from stakeholders and the TEP, the final Technical Guidance identifies several key areas of consensus and defines seven risk adjustment best practices. Among other practices, it recommends that measure developers prepare a conceptual model that illustrates the potential pathways between the social and/or functional risk factors, patient clinical risk factors, and the measured outcome. It establishes a minimum set of social and functional risk factors to consider within the overall risk adjustment strategy. It reflects the consensus that race is qualitatively different from other social risk factors and should be considered for adjustment on a case-by-case basis. And it articulates guidance for stratification analyses, as this can be a critical tool for reporting on differences in measure results between patient subgroups.

The specific design of risk adjustment models is left up to developers. The statistical approaches identified within the Guidance are not intended to be overly prescriptive as to limit the use of novel methods or to add significant burden to measure developers. The Guidance is intended to facilitate greater consistency in the development and evaluation of risk adjustment models by guiding developers through a step-by-step process to get there.


About National Quality Forum
The National Quality Forum (NQF) works with members of the healthcare community to drive measurable health improvements together. NQF is a not-for-profit, membership-based organization that gives all healthcare stakeholders a voice in advancing quality measures and improvement strategies that lead to better outcomes and greater value. Learn more at www.qualityforum.org.