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Population-based payment models need social as well as clinical risk adjustment, report says

COVID-19 emphasizes how the social determinants are connected to physical health, according to Humana and National Quality Forum.

Susan Morse, Managing Editor

The COVID-19 crisis has underscored the connection between social needs and physical health, according to a new study by Humana and the National Quality Forum.

The authors argue that because of the effects that social determinants have on health, population-based payment models should include a social-risk adjustment, as well as a clinical risk adjustment.

Humana and the National Quality Forum published their findings in a new paper published in The New England Journal of Medicine. "Clinical and Social Risk Adjustment – Reconsidering Distinctions" was co-authored by Dr. William H. Shrank, Chief Medical Officer for Humana and Dr. Shantanu K. Agrawal, president and CEO of the National Quality Forum.

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Adjusting payment for social risk will provide incentives for addressing health-related social needs, the physicians said.


Social, behavioral and environmental factors – such as access to healthy food, a safe environment and social support – affect physical and mental health, which is why these aspects need to be incorporated into payment models, according to the authors.

A focus on upstream causes of poor health has been an emphasis of more recent value-based reimbursement models, they said.

COVID-19 has emphasized social needs gaps, as people socially isolate. The coronavirus pandemic is particularly hard on historically disadvantaged populations and others facing challenges with the social determinants of health, Humana said.

In addition to social needs, individuals face barriers accessing healthcare services and engaging in preventative health, leading to a higher prevalence of conditions such as diabetes and hypertension. Underlying chronic conditions are a major risk factor for individuals exposed to the coronavirus.


The analysis and recommendations in the NEJM article build on a recent NQF and Humana collaboration on food insecurity and health.

Providers know that addressing the social determinants of health, such as food insecurity and isolation, is key to better health outcomes and lower costs.

The National Quality Forum is a not-for-profit, membership-based organization that works with members of the healthcare community to drive measurable health improvements.


"Growing evidence indicates that socially disadvantaged people have comparatively worse health outcomes, suggesting that clinical and social risk are related," said Agrawal. "To improve the health outcomes of all people, including the disadvantaged, we must consider this growing body of evidence as part of a comprehensive, 21st century approach to risk adjustment."

Shrank said, "The COVID-19 crisis has underscored the inter-relatedness of social context and physical health. Our proactive outreach to our COVID-19-positive and highest-risk members has uncovered high rates of social isolation and considerable barriers to accessing healthy food, which put them at higher risk for bad outcomes. Given the associations between social risk and clinical risk, it stands to reason that risk adjustment for payment models should incorporate the breadth of patient characteristics that predict the need for healthcare services."

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