News: NQF and Humana release paper calling for new risk adjustment model

In a recent joint paper published in The New England Journal of Medicine, the National Quality Forum (NQF) and Humana called for a new risk adjustment model that accounts for both clinical factors and social determinants of health.

The paper argues for “evaluating social risk adjustment alongside clinical risk in population-based payment models, to provide incentives for addressing health-related social needs to improve health outcomes, rather than lowering the standards for their care,” according to the Humana release.

The authors didn’t recommend a specific risk adjustment model in the paper but instead called for a broader conversation about the topic. This conversation, according to the paper’s authors, must include engaging providers about what resources are available to them, and presenting data to stakeholders and the public in an actionable way.

Studies have shown that SDOH and health outcomes are inextricably linked, yet SDOH are largely excluded from risk adjustment models. Most risk adjustment models instead rely solely on factors such as patient age, sex, surgical history, and medical conditions. The fact that CMS is calling for feedback regarding SDOH codes as part of the fiscal year 2023 inpatient prospective payment system proposed rule may indicate a called-for sea change is on the horizon.

“Adopting methods that account for all factors that influence patients’ risk, and those factors’ interdependence, could help create a more equitable health care payment system that better serves patients, including the most disadvantaged members of society,” the paper’s authors wrote.

Editor’s note: To read the full article from the NQF and Humana, click here. To read the press release from Humana, click here. To about CMS’ call for feedback on SDOH codes, click here.