CMS Gets Serious About Health Equity

CMS has been promoting health equity for a while, releasing their Health Equity Framework in April 2022 as a milestone. They have outlined why health equity is important, their goals and how they will be rewarding healthcare entities that deliver quality care to higher percentages of underserved populations.¹ Also, CMS has continued to release policies that support the five goals of their health equity framework since introducing it. 

In April 2024, CMS released the Medicare Advantage and Part D Final Rule² to further support health equity, introducing the health equity index which introduces a reward as indicated in their strategic plan.  The new measures will impact Star ratings beginning in 2027, and the first bonuses will be paid in 2028 for those plans that meet the standards.³ 

Now is the time to get a good understanding of the rule and to be proactive with a plan to meet requirements. 

Understanding Your Plans Impact 

The first step is getting familiar with the ruling. The details can be complex and it’s important to fully understand the scope. The ruling is on the CMS website, and you can get the details there.²  

Next you need to use demographic data to identify your Medicare Advantage (MA) members who are part of the three risk factors (social risk factors or SRF) groups named by CMS: dually eligible, persons with a disability and persons receiving a low-income subsidy. When you know who these individuals are, prioritize your analysis for MA contracts that have a large population of members meeting the CMS criteria.   

At this stage, you should be prioritizing resources to do the rest of your analysis and begin developing your plans for improvement. For example, if you have an MA contract that doesn't qualify for the index, you may choose to deprioritize analysis of those members and your scores at this time. 

Complete Your Initial Analysis of Your Quality Measures to Compare to Core Population 

Identify the key quality measures you want to analyze. While CMS has not yet defined which measures will be part of the health equity index, you may consider starting with preventive care measures or chronic condition management measures. 

Use the results on the measures you have chosen and get an understanding of where you have strengths and opportunities in each contract. Introduce the three SRF populations specified by CMS. Compare those measures for your base population and your SRF population to identify which measures have the most significant disparities between your standard population and your SRF population.  

Identity Drivers of Disparities Found, Including the Social Determinants of Health 

Knowledge is power. When you can identify areas of need, you can plan and activate intervention programs to improve health outcomes.  

With data, you can augment your view of your entire population, not just the persons that are part of the three social factor risk groups, with social attributes and profile information. 

Using your claims data, health risk assessment data and social determinants of health data, complete an analysis of the SRF population and your standard population. Compare individuals who are doing well on those quality and outcome measures, with those are not doing as well as you would like. Include your analysis of the social risk factors that could influence members ability to get their medication or keep regular appointments with their physician. You may want to consider factors like distance to a healthcare professional, transportation challenges or economic stability issues. All of those factors could be influencers of how well a person is able maintain regular care for their condition. 

The next step is prioritization. Identify the specific measures and groups that have the largest disparities for those persons within the SRF populations. This will help you begin to understand why these individuals have different outcomes.  

The purpose of the health equity index is to reward efforts made by health plans that achieve  health equity in underserved groups. To get results, health plans will need to develop interventions at a local and individual level for the persons who need help, fueled by thorough analysis of their populations. 

 

References:

1. CMS Strategic Plan
   https://www.cms.gov/files/document/health-equity-fact-sheet.pdf
2. 2024 Medicare Advantage Final Rule (CMS – 4201 – F) 
   https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f
3. 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F),
   https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f