NRHI CEO Elizabeth Mitchell Responds to the New York Times on Measuring Outcomes for Disadvantaged Populations

A recent article by Robert Pear, ‘Health Law’s Pay Policy is Flawed, Panel Finds’, highlighted the challenges of trying to measure health outcomes for disadvantaged patients, and the growing demand that healthcare providers be accountable for those outcomes.

Unfortunately neither the column nor the draft National Quality Forum report that it references adequately addresses the complexity – and potential solutions – to this real and difficult problem.

Today’s risk adjustment systems are flawed and current payment structures are also flawed. I am a member of the NQF Board and applaud them for taking on the issue of Socio-Economic risk adjustment. The NQF is doing the country a service by bringing this issue to the national forefront and bringing multi-stakeholder voices and perspectives to its solution.

Still, I believe the recommendations from the panel convened by NQF are simplistic and could lead to unintended consequences. The report’s laudable goal is to account for socio-economic factors when measuring provider performance, but the recommendations actually have the potential to limit accountability for poor outcomes.

It would be unfair to expect providers to address the complex challenges disadvantaged patients face with the same resources required to treat the challenges of well-off, insured patients who enjoy extensive social supports.

However, it would also be unfair – to patients – to establish a ‘lower bar’ of performance for those facing social and economic hardship. The real issues are lack of insurance coverage, lack of education, lack of access to primary care and behavioral health services.

Risk adjustments like those proposed could mask the severity of the problem. Worse, they suggest that is to be expected and tolerated.

And as Dr. Kate Goodrich of the federal Centers for Medicare and Medicaid Services rightly points out in the Times story, socio-economic risk adjusters hold the potential of “rewarding providers who provide a lower level of care for minorities and poor people.”

The recommendations to risk-adjust the performance measures may address some concerns about ‘penalizing’ providers for poor outcomes that are outside their control. But they imply that we have set a bar in this country for what is fair to expect, and that bar is set at the level of the educated, well-off patients who don’t struggle with transportation, social service needs, mental health or other barriers to good health outcomes.

An alternative view is that we need to measure outcomes for all patients, regardless of socioeconomic status. We should hold ourselves accountable for the risks and challenges faced by poor patients and provide the resources – to providers and in communities – to help address those risks.

There are some resources in place. Many hospitals in the U.S. are granted non-profit status in recognition of the work they do on behalf of the disadvantaged in their communities. Some receive ‘Disproportionate Share’ payments in recognition that they serve a ‘disproportionate’ number of disadvantaged patients. CMS is also boosting payments to some primary care centers to acknowledge the challenges they face serving the underserved.

These are not perfect systems, but are an important direction to evaluate and potentially improve. If providers can demonstrate that these payments inadequately compensate them for caring for community needs, they should make their case: States, the federal government and insurance companies should be expected to pay fairly to those practices, facilities, and importantly, to other community partners, which serve a disproportionate number of patients with socioeconomic disadvantages.

The direction that we are collectively taking in the US is towards greater accountability across the healthcare industry. As providers organize themselves into ‘Accountable Care Organizations’, they are expected to be accountable for population health. Population health includes the entire population and happens outside of the hospital. This is forcing new arrangements, relationships and interventions and it is our best hope of improving health and reducing health spending. We have a corresponding obligation to create accurate, fair measures, and change our payment systems to ensure that they reflect and support these values.

The National Quality Forum’s draft report inspired over 600 public comments – testimony to the widespread concern about these problems. We need to have this conversation and we need to recognize and address the real needs of patients- regardless of socioeconomic status.

The NQF report has brought this to the forefront and has engaged the key stakeholders. While it is important to consider the real and important concerns of providers, we hope that the final recommendations account for the fundamental needs and challenges of our most vulnerable patients.