Addressing social risk factors in value-based payment: Adjusting payment not performance to optimize outcomes and fairness

As payers are increasingly holding providers financially accountable for outcomes under value-based payment arrangements, there is growing concern that organizations caring for populations with greater social risk factors are unfairly penalized. Those voicing this concern often suggest that it is necessary to adjust performance scores for social risk factors to fairly assess and reward providers caring for populations with differing levels of socioeconomic vulnerability. The underlying premise is that achieving favorable outcomes for patients with greater social risk is more difficult or requires different resources than achieving the same level of outcomes in a more socially advantaged population. Other observers object to adjusting performance scores for social risk factors, seeing this as excusing or accepting of lower-quality care being delivered to socially at-risk populations and as masking lower performance with statistical adjustments.