NQF: Keep Social Risk Factors Out of Most CMS Hospital Readmission Measures

The debate continues over whether hospitals that treat a lot of low-income patients should get a break on readmissions penalties levied by Medicare.

Intuitively, it makes sense. Using readmissions as a measure of high quality care means that readmissions measures should be adjusted for hospitals that treat sicker patients.

Data shows that some social factors, such as the trappings of poverty, can make patients sicker.

So, should hospitals that treat a lot of low-income patients with sub-standard housing and limited access to healthful food get a break on readmission penalties levied by Medicare?

It is a raging debate in health policy world. The latest development comes from the National Quality Forum, a national clearinghouse for quality measures. The group has declined to endorse adding social risk factors to most of the Centers for Medicare & Medicaid Services readmissions measures.

The report puts it this way:

"At this time, the CSAC (Consensus Standards Approval Committee) supports continued endorsement of the hospital readmission measures without SDS (sociodemographic.) adjustment based on available measures and risk adjustors."

The next sentence is a bit clearer: "The CSAC recognizes the complexity of the issue and that it is not resolved."

It is far from resolved, some would say.

Medicare's readmission measures adjust for age, medical history, and comorbidities. But some argue that it is unfair to expect safety-net hospitals to be as effective in preventing readmissions as other facilities because their patients are sicker.

Others argue that an adjustment to the readmissions measures could give poor quality hospitals a pass.

Safety Net Hospitals: Socioeconomic Status Matters

Leading the push in favor of adjustment is America's Essential Hospitals, a trade group for more than 300 safety-net hospitals.

Beth Feldbush is the group's vice president of policy and advocacy. She says the NQF findings are not a surprise. Still, NQF is not closing the door on adjusting readmission rates. More and better research is needed, she says.

"Throughout the process, NQF had acknowledged that the lack of data is problem. Without data, it is hard to come to a conclusion one way or another."

John B. Bulger, DO, is the chief medical officer, population health at the Geisinger Health System, a 12-hospital system based in Danville, PA. He is also the co-chair of the readmissions committee of the NQF's measure endorsement project.

An Evidence-based Stance

Bulger says the committee was very open minded in considering the possible impact of social factors on readmission measures. But because committee members can only review the measures that are brought before them, their task is to make recommendations based on the reliability of those measures.

"We purposely did not want it construed that the committee thinks social determinants don't matter, or [that] socioeconomic status doesn't matter," he says.

"That is absolutely not what our conclusion was. The conclusion was, as it was tested in the measures that were in front of us, it didn't make a discernable difference."

Detractors: Adjustments Would Create a Double Standard of Care

Harlan Krumholz is a cardiologist and the director of Center for Outcomes Research and Evaluation (CORE) at Yale. His team helped develop CMS's readmission measures. In a written response to questions from HealthLeaders, he pointed out that many hospitals serving patients with low socioeconomic status do well with readmissions.

It is not clear, however, that those that do poorly do so because of social risk factors not accounted for in the readmission measures, he noted.

It is possible that these patients get less attention or less help in the transition from hospital to home. But overall, there is practically no effect in adding socioeconomic status to the risk models, according to Krumholz. His team published findings last summer asserting this idea.

Krumholz is in the camp, along with The LeapFrog Group and Consumers Union, that believes adjustments will make it difficult to identify poor performing hospitals and will essentially create a double standard in quality of care.

Feldbush said her member hospitals are "insulted" by the suggestion that at safety net hospitals provide inferior care.

"That's implying that our patients' lives are not valuable and our hospitals don't care," she said, "That is patently false."

Both NQF and safety net hospitals agree that more research is needed to examine the link between readmissions, social risk factors, and quality.

In the meantime, Congress has stepped in. A provision in the sprawling 21^st Centuries Care Act, a grab bag of measures passed late last year, mandates that CMS start adjusting readmission measures to account for the social determinants of health.

The agency has proposed an adjustment based on dual eligibility the status of patients who are old enough to qualify for Medicare and needy enough to also qualify for Medicaid.

For a full update on the debate, see the comments section of the proposed rule in the Federal Register. Some systems and groups support it, others want more data from CMS, and others would like to see the measures refined.