Health Equity Framework for Medicare Organizations
By Erica Everhart
March 3, 2023
Health Equity is a Key Focus for CMS
In October of 2021, CMS’s Center for Medicare and Medicaid Innovation (CMMI) released their Ten-Year Strategic Plan which has five main pillars, one of which is Advancing Health Equity. They also outlined one of their key goals, to have all Medicare beneficiaries in some form of accountable care relationship by 2030. Achieving this goal will require reaching the most underserved populations, who are sadly the least likely to currently be enrolled in any sort of accountable care organization.
Model elements aimed at reducing healthcare disparities and at reaching underserved beneficiaries are a part of all recently released payment models, such as the Kidney Care Choices model which includes a stratified benchmark that rewards dialysis providers who treat more underserved beneficiaries. The ACO REACH model also includes a stratified benchmark, and goes a step further incorporating a required ACO REACH health equity plan and the collection of self-reported demographic and social determinants of health (SDOH) data.
Health equity is also wending its way into Medicare Advantage and the Medicare Shared Savings Program. For the first time, CMS is proposing the creation of a health equity index to be included as part of the Medicare Advantage Star Ratings formulas beginning in 2027. This Health Equity Index (HEI) is intended to reward contracts who narrow inequities faced by beneficiaries with certain social risk factors. These social risk factors would, at least initially, be beneficiary’s dual eligibility for Medicare and Medicaid or receipt of the Limited Income Subsidy.
Beginning in 2023, the Medicare Shared Savings Program (MSSP) is accounting for increases in the demographic portion of risk scores when calculating risk score caps, utilizing a similar methodology as ACO REACH. Every beneficiary has a risk score composed of two portions: demographic relative factors and disease relative factors. Demographic relative factors account for a beneficiary’s age, gender, dual-eligible status, and whether they initially obtained Medicare due to a disability. In calculating risk score caps in MSSP and ACO REACH, the cap will be relative to any increase or decrease in demographic relative factors. You can read more about how this works in our explainer on risk scoring in ACO REACH.
Participating in the ACO REACH Model?
Learn how to be successful in the model.
Part of the Medicare Shared Savings Program (MSSP)?
Learn how to improve performance in MSSP.
What Might Organizations Do to Plan For Health Equity Requirements?
There are strong signals that each Medicare initiative will include increasing health equity components and any organization who is participating or considering participating in a CMS program should begin planning for health equity requirements now. There are three consistent ways that we see CMS asking organizations to think about health equity:
- Identify and reach out to underserved populations,
- Identify and work to close health equity gaps, and
- Collect and report demographic and social determinants of health data.
Identify Underserved Populations
Most organizations are aware that they have beneficiaries in their service area that are considered “underserved.” The struggles we hear from CareJourney members are in finding these beneficiaries, understanding the type of healthcare they are receiving, and engaging them to hopefully initiate an accountable care relationship.
Before ACOs can identify underserved populations for CMS programs, they must understand the definition of an underserved population. We can look to CMMI’s guidance on this. CareJourney uses the definitions of equity and underserved populations that are referenced in the FAQs to the Ten Year Plan (question 8, pg 2) which in turn references Biden Executive Order 13985.
Health Equity, Defined
The term “equity” is defined as the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.
In short, underserved populations are beneficiaries who are: racial minorities, religious minorities, LGBTQ+, disabled persons, people in rural areas, or people affected by persistent poverty or inequality. With the proper data sets, we can identify a beneficiary’s race, disability, rurality, and poverty. As CMS begins to collect beneficiary reported demographic data, the accuracy of race data (patient reported demographic data is the gold standard!) will improve. To identify a beneficiary’s rurality, we use the Rural-Urban Commuting Area Codes (RUCA Codes) matched with the beneficiary’s five digit zip code from the Medicare claims data. In determining poverty, CMS has centered primarily on a beneficiary’s dual eligibility for Medicare and Medicaid, receipt of the Limited Income Subsidy, and in ACO REACH, CMMI has incorporated the Area Deprivation Index into the stratified benchmark calculation as a further indicator of persistent poverty.
CareJourney is unable to determine a beneficiary’s religion or LGBTQ+ status with the data available to us, however as CMS integrates the collection of SDOH data into new payment models, data on these underserved populations might become available for additional research.
Many CMS programs incentivize ACOs to craft outreach methods to bring additional underserved beneficiaries into an accountable care relationship. Once an ACO identifies a group of beneficiaries in a region who match the “underserved” definition, they can then profile these beneficiaries to see which physicians they are seeing or which hospitals patients are using for care. ACOs can also dig deeper into the data to look at these beneficiaries’ utilization patterns, preventative care, spend, quality measures and more. Organizations can use this information to create highly tailored outreach programs that meet underserved beneficiaries where they are and provide the care that a particular, unique community needs.
Another approach to reaching underserved populations is to look at the location of healthcare providers who practice in rural areas or areas with distressed Area Deprivation Indices. ACOs can work with these providers to supply them with the support necessary for learning the ropes to be successful in accountable care. By doing this, ACOs will either improve the care for beneficiaries who are already in accountable care relationships, or they will bring additional underserved beneficiaries into ACOs where they can receive all of the benefits an ACO provides that underserved populations desperately need.
Identify and Work to Close Health Equity Gaps
As discussed above, the first step in identifying health equity gaps is to identify underserved populations. The second step is to study the underserved population in relation to the “properly served” population to identify health equity gaps. The ACO REACH model has a requirement where all participating ACOs must submit a Health Equity Plan in which they (1) identify an underserved population in their aligned patient base; (2) identify a disparity in care for this population; (3) identify and describe interventions the ACO can take to address the disparity; (4) identify community groups with which the ACO can work to address the disparity; and (5) report the ACO’s progress in narrowing the disparity to CMMI.
At CareJourney, we are learning about how claims data can inform organizations, from Medicare Advantage organizations to MSSPs to health systems to REACH ACOs, in their health equity strategy. While ACO REACH has given us the opportunity to create tangible reports with members, we are also working more broadly with a number of organizations who understand that working towards health equity is not only an increasing requirement for CMS programs, it is the correct pathway to provide better healthcare to everyone they serve.
We are evaluating how three population groupings: dual-eligible beneficiaries, beneficiaries in distressed areas, and racial minorities perform relative to their majority population counterparts along hundreds of measures. As we look at different health systems, ACOs, and geographical regions, we are amazed at the variation in disparities. However, one thing is very clear: dual eligible beneficiaries and racial minorities face significant inequities in healthcare. Dual-eligible beneficiaries are more than twice as likely to be hospitalized in a given year with a preventable admission and more than twice as likely to visit an emergency room than their non-dual eligible counterparts. African-Americans are twice as likely to have a preventable hospital admission for a chronic disease than Non-Hispanic White beneficiaries.
Although health inequities are stark between racial minorities and Non-Hispanic White beneficiaries, CMMI recently released guidance on the ACO REACH Health Equity Plan requirement clarifying that REACH ACOs may not use a federally protected class such as race or gender as the sole grouping for which they target interventions aimed at narrowing health inequities. As we help our Members approach their health equity plans for ACO REACH, we have primarily focused on dual eligibility status and distressed areas identified by ADI scores. We continue to provide data broken out by race groupings to look for disparities, because we believe that ACOs should take racial disparities in healthcare into account, even if they are prohibited from using racial groups as the groups they are targeting for purposes of the ACO REACH health equity plan.
It is important to note that CMMI encourages REACH ACOs to look at any data available to them in locating underserved populations. Many ACOs have data that they have collected themselves that they can pair with electronic health records data to identify disparities. Some states have additional data resources for helping to locate underserved populations. There are additional data sources, such as the CDC’s Social Vulnerability Index, that an ACO can use to identify underserved populations, especially in urban areas where the ADI scores tend to be lower.
Collect and Report Demographic and Social Determinants of Health Data
The final component that ACOs will likely need to tackle with Medicare programs is the collection and reporting of beneficiary reported demographic and Social Determinants of Health (SDOH) data. Beneficiary reported demographic data is the gold standard for demographic data. ACO REACH requires the collection and submission of demographic data for PY2023 and SDOH data collection and submission will likely be a requirement for PY2024.
CMS has given ACOs two options for submitting this data: a CMS provided Fast Healthcare Interoperability Resources (FHIR) questionnaire app that providers can use to collect and report this information or an Excel template.
In addition, we are proud to have helped launch Sync for Social Needs, at the White House Conference on Hunger, Nutrition, and Health in response to the Biden-Harris’ Administration’s call to action for private – and public -sector commitments to end hunger, reduce diet related disease, and close disparities among impacted communities.
This multi-stakeholder, zero dollar coalition is committed to:
- Define FHIR- based Standards in order to solidify a single approach for the exchange of social needs screening data.
- Align on the appropriate quality measures and language to use for screening given the sensitive nature of these questions in order to improve data collection and lower burden.
- Conduct real world testing in order to pioneer new approaches and generate feedback on what does or does not work.
If you aren’t yet part of this exciting initiative, please reach out and join!
Health equity is non longer simply a buzzword. The pursuit of health equity is a key priority for CMS because health inequities are a sad reality for large swaths of the population in the United States. Organizations, including ACOs, are being asked to look inward at their own practices to identify where they can make changes so that everyone they serve receives the correct care, no matter who they are or where they live. ACOs are also being asked to look outward to identify and include in their membership those beneficiaries they are not serving, specifically those that are vulnerable or underserved and desperately need the coordinated care and other benefits that ACOs provide.
If your organization is thinking about health equity, let us know how we can help.