Much of the work to date has examined the role of SRFs at the patient level, with an emphasis on Medicare-Medicaid dual-eligibility because of its availability in CMS datasets however, quality metrics may also be affected by SRFs at the neighborhood level. Quality metrics in rating systems provide a common reference point for comparing hospitals, but the impact of SRFs may call into question the fairness of hospital rating systems for hospitals serving disadvantaged communities. In comparison, hospital rating systems are more complex and may be more susceptible to the influence of SRFs, because they include a broader array of quality metrics. Similarly, many of these value-based programs focus on a single quality outcome or objective (e.g., reducing readmission). 8 Consequently, value-based programs have largely focused on this single surrogate marker in risk adjustment strategies. 3 In a 2016 report to Congress evaluating nine Medicare-sponsored value-based programs, dual-eligibility, used as a surrogate marker for high SRFs, was strongly associated with worse patient outcomes. While some SRFs, such as race and socioeconomic status, have been more consistently associated with quality metrics (e.g., hospital readmission), the influence of other SRFs, such as education or marital status, remains less clear. 4– 7 However, there is little agreement about the specific SRFs that most significantly influence quality of care. Social risk factors (SRFs) have been shown to influence numerous quality metrics used in value-based payment programs, such as the Merit-based Incentive Payment System and Hospital Readmissions Reduction Program.
3 While these risk adjustment strategies have historically accounted for medical complexity, they have only recently begun to address social complexity. As such, hospital rating programs have begun to implement risk adjustment strategies, which attempt to account for the differences in risk when calculating a score or rating. For instance, a medically complex population with fewer resources can be more challenging to care for than a healthier population with many resources. 1, 2 However, a hospital’s quality can be heavily influenced by the risk of its patient population. The Centers for Medicare and Medicaid Services (CMS) and others use quality metrics (i.e., readmission rates, surgical site infection rates) and survey data to create scores used for hospital ratings. From the hospital perspective, ratings can influence payments from value-based care programs and are used in payer-provider contract negotiations. From the patient perspective, hospital ratings could be helpful for deciding where to get care. Hospital ratings are a cornerstone of modern healthcare, especially in an era of rapid information flow and growing public transparency.
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