National Quality Forum Recommends Sociodemographic Risk Adjustments

The National Quality Forum (NQF) has issued a draft report recommending changes to its current policy in order to assist the health care community in reducing disparities in care, while simultaneously gathering accurate data regarding the quality of care delivered by providers. The NQF’s 26-member expert panel’s concern with the Forum’s current policy—to not adjust performance measures for sociodemographic factors—is that it may be leading to false conclusions about a provider’s quality of care and could be unintentionally weakening the number of providers that serve disadvantaged populations.


Since the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) was implemented, lower costs and higher quality of care have been at the forefront of the health care debate in the U.S. Accountability measures such as hospital readmission penalties and Medicare spending per beneficiary have raised concerns on whether performance measures should be adjusted for sociodemographic factors in an effort to increase the accuracy of provider performance results. In order to answer that question, NQF assembled a panel of 26 experts and stakeholders with a range of expertise, from socioeconomic disparities to risk adjustment and performance measurement methods.

Areas of Concern

The expert panel found three areas of concern in reaching its conclusion that NQF’s current policy is unintentionally weakening the number of providers that serve disadvantaged populations: (1) providers that avoid serving disadvantaged individuals to avoid being labeled “poor performers,” which decreases access to care for vulnerable patients; (2) the shift of performance-based funds to providers that treat affluent patients, which could lower the amount of resources available to treat vulnerable populations; and (3) payers who avoid providers because they treat disadvantaged populations, which could inaccurately reflect a provider’s quality of care. The panel also noted that the NQF’s current policy could be worsening disparities, according to the report.


In response to their findings, the expert panel set forth eight recommendations: (1) create different analytical methods according to different purposes of accountability and identifying and reducing disparities; (2) revise NQF risk adjustment criteria to include sociodemographic factors where appropriate; (3) establish guidelines for risk factor selection and the inclusion of sociodemographic adjustment; (4) identify what information is needed when outcome measures could be adjusted due to sociodemographic factors; (5) evaluate the impact of accountability applications on disadvantaged patient populations and the health care providers that serve them; (6) ascertain and develop a collection of standard sociodemographic variables for measuring performance and identifying disparities; (7) expand NQF’s role to provide guidance on the implementation of accountability performance measures; and (8) clarify that endorsement relates to performance measures as “specified and tested for a specific patient population, data source, level of analysis, and setting.”

Contrasting Views

Not everyone supports the expert panel’s recommendations, reported the New York Times. “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” stated CMS director Dr. Kate Goodrich. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Others share the NQF’s concerns: “Lower-income patients have higher readmission rates,” according to the Medicare Payment Advisory Commission, “and major teaching hospitals, which serve large numbers of indigent patients, face the highest penalties.”