In October of 2021, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) unveiled its 2030 vision to achieve “equitable outcomes through high quality, affordable, and person-centered care.” One of the objectives to achieve this goal is to focus on “advancing health equity.” Dr. Dora Hughes, the Chief Medical Officer of CMMI, recently outlined in a blog post the initiatives that CMMI has already conducted and is proposing to implement to advance health equity.
CMS defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” In working to achieve health equity in testing its payment and service delivery models, CMMI has committed to the following:
- Developing new models and revising existing models to promote and incentivize equitable care.
- Increasing participation of safety net providers.
- Increasing collection and analysis of equity data.
- Monitoring and evaluating models for health equity impact.
Developing new models and revising existing models to promote and incentivize equitable care.
CMMI has revised the Medicare Advantage Value based Insurance Design Model, the ACO Realizing Equity, Access, and Community Heath (ACO REACH) Model, and the Maryland Primary Care Program, which is a component of the Maryland Total Cost of Care Model, to promote a more direct focus on health equity. Some of the revisions included providing supplemental benefits, such as food, transportation, and housing assistance to beneficiaries with chronic illness and unmet social needs, and providing payments to allow for additional support for care management services. CMMI is also collecting better sociodemographic data, requiring model participants to create and implement health equity plans, and ensuring screening of beneficiaries for health-related social needs. CMMI also introduced the Enhancing Oncology Model (EOM) that focuses on cancers that disproportionately affect underserved populations and includes many of these same model policies.
Increasing participation of safety net providers.
To increase model participation among safety net providers, CMMI conducted external and internal analyses. The external analysis included engaging in interviews and listening sessions with safety-net provider stakeholders to identify any barriers to safety-net provider participation. The internal analysis looked at qualitative data related to model application requirements to see if they provided any barriers to participation. This data will be used to operationalize strategies for including more providers that serve Medicaid beneficiaries, as well as federally qualified health centers in CMMI Models.
Increasing collection and analysis of equity data.
CMMI uses data to evaluate findings and inform future model design. CMMI would like to collect equity data to “better stratify and evaluate model outcomes for beneficiary populations defined by factors such as race, ethnicity, gender, geography, disability, sexual orientation, and gender identity.” CMMI has already started to collect equity data in the ACO REACH Model, which requires ACOs to collect sociodemographic data and health-related social needs data. CMMI is also working with other federal agencies and states to obtain equity data in the Integrated Care for Kids Model and the Maternal Opioid Misuse Model.
Monitoring and evaluating models for health equity impact.
CMMI is following a two-pronged approach to evaluate models and measure their impacts on underserved populations. CMMI will publish findings from a retrospective, cross-model review focused on underserved populations for older models. Additionally, this includes current models that will have expanded analytic work to capture health equity impact. For new or modified models, CMMI is designing multiple new forms of analyses to provide a thorough understanding of the health equity impact of the models. In addition to evaluations, CMMI is developing analysis such as “leading indicators” to provide early signals of a model’s performance.
Looking ahead in 2023
For the rest of 2023, CMMI is continuing to refine and improve their current efforts to address health equity. One expectation is that all new models will include health-related social needs screenings and referral components when feasible. CMMI has also, in alignment with cross-agency efforts, developed recommendations for measuring quality of care for underserved populations. Additional efforts CMMI would like to apply in 2023 include:
- Sharpening the focus on the needs of other underserved populations that are not well represented in models.
- Exploring options to build upon and support earlier investments in rural health, to address the unique access and health care needs of rural and geographically isolated communities.
- Continuing to explore mechanisms for social risk adjustment of payment, such as the use of dual eligibility status to better account for social risk.
- Addressing the high cost of drugs, in response to the Executive Order on Lowering Prescription Drugs.
- Identifying and remedying model designs that may lead to inequities.
Dr. Hughes said that CMMI’s equity to-do list is “ambitious but necessary… to ensure that our long-term transformational work equitably benefits all beneficiaries we serve.”
We will keep you informed of new CMMI models and their focus on addressing health equity as the agency provides more updates.
