To design equitable value-based payment systems, we must adjust for social risk

In its recently released report to Congress, the Department of Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) concludes that many quality measures used in value-based payment programs—process and outcome measures specifically—should not be adjusted for the social risk of patient populations. Social risk factors exist at both individual and community levels and include challenges such as poverty, food insecurity, housing instability, homelessness, and lack of social support, all of which can affect health outcomes. The ASPE claims that social risk adjustment could mask unspecified inequities or excuse poor quality of care. But the report does not sufficiently articulate or support this claim. In this post, we clarify the distinction between health care quality and outcomes, show how differences in income and social risk across patient populations can affect providers’ quality ratings in value-based payment systems, and explain why risk adjustment for social needs helps advance quality and health equity.