– by Lynn Kryfke, MSN, RN, Sr. Consultant, Risk Adjustment | Jon Rogers, Sr. Consultant, Risk Adjustment

The CDC defines Health Equity as the state in which everyone has a fair and just opportunity to attain their highest level of health. Despite progress, health disparities remain a persistent issue according to the NIH Common Fund, especially affecting racial and ethnic minorities who have higher rates of certain diseases and death compared to the general population.

Understanding Health Disparities

Health disparities are preventable difference that occur in disease burden, injury, violence, or access to optimal health. These disparities are experienced by populations that have been socially or economically disadvantaged, live in certain geographic areas, or are affected by environmental factors.

The Impact of Health Disparities and the Need for Action

COVID-19 underscored the deep inequities in our healthcare system, according to the Journal of the American Medical Association (JAMA) Forum. The disproportionately high levels of COVID-19 cases, hospitalizations, and deaths among racial groups of color reflect poorer underlying health, housing, and job conditions experience by minority groups, as well as an inequitable distribution of health resources.

Government Efforts and Initiatives to Address Disparities

Currently, various agencies are addressing health inequities through efforts to identify, report, and develop interventions. The CMS Minority Research Grant Program supports research into public health disparities and the CMS Offices of Minority Health administers grants through the Health Disparities Health Equity Data Access Program (HEDAP) to advance Health Equity research. Additionally, the Commonwealth Fund’s Advancing Health Equity Program collaborates with NCQA to improve the consistency and accuracy of data used to measure, monitor, and enhance Health Equity. The NIH Common Fund initiated the Community Partnerships to Advance Science for Society (ComPASS) Program to promote community-led Health Equity structural interventions and reduce health disparities through partnerships.

CMS Efforts to Advance Health Equity

CMS has been very active in working to advance Health Equity by addressing disparities within our health system. Given current outcomes, CMS has prioritized Health Equity to reduce disparities in health and improve outcomes for Medicaid, Medicare and Marketplace beneficiaries.

CMS has focused on payment rules that advance Health Equity and expanding access to care and services for people who are part of underserved communities, including:

  • Adding community health workers, care navigators and peer support workers to address health-related social needs that impact care, including mental healthcare, in a culturally sensitive way
  • Coding and payment for Social Determinant of Health Risk assessments
  • Separate coding and payment for community health integration services to include person-centered planning with health system coordination

Incentivizing Health Equity in Medicare and Marketplace Contracts

In addition, CMS is improving Health Equity by incentivizing Medicare, cost, pharmacy and drug plan contracts to perform well among enrollees with specified social risk factors with a Health Equity Index Reward. CMS will also require health plans to implement a utilization management committee with expertise in Health Equity to conduct an annual analysis of the use of prior authorizations that impact low-income subsidized enrollees, those that are dually eligible and/or disabled with one or more social risk factor.

Enhancements to Marketplace Plans

Marketplace plans have seen some changes as well; CMS added requirements to refine the essential health benefits based on clinical evidence, address health and healthcare disparities as a specific topic in quality improvement programs, and collect new data elements on ZIP Codes, race and ethnicity.

Strategic Planning for Health Plans

Health plans have much to consider in implementing the CMS requirements. Medicare, Medicaid and Marketplace plans must make Health Equity and health disparities a priority.

Here are some important elements to include in strategic planning for what’s ahead:

  • Create organizational awareness and develop leadership and staff knowledge
  • Identify gaps in health plan programs and resources to address requirements
  • Develop programs and methods to obtain additional data sources to gather information on enrollees
  • Take proactive steps to leverage critical data for enrollees/beneficiaries and use the information to enhance individual health outcomes
  • Utilize additional data sources to provide a more accurate accounting of an enrollee’s health to further the capabilities and accuracy of risk adjustment, case management and population health programs

As we close out 2023, it’s crucial to align leadership, staff, and programming to tackle Health Equity and disparities. This alignment will be instrumental in achieving your plan’s goals and serving enrollees in the future. Success and improved health outcomes can be achieved by promoting cross-functional collaboration and leveraging resources to obtain comprehensive and accurate enrollee information.

Stay on top of trends related to how risk adjustment evolves to capture the complexities of health and well-being. ATTAC Consulting Group has the expertise and experience to keep accuracy of risk scores in the forefront of your organization’s risk adjustment program. With a pulse on the latest CMS and OIG trends, and the knowledge of where to look, ATTAC is uniquely positioned to aid in your organization’s risk adjustment retrospective programs.