For years, providers have been talking about tackling health equity gaps in healthcare.
But in 2023 new requirements from the federal government mean it is now time for some to walk the walk.
“This has been twenty years in the talking stage,” said Paul Shields, D.O., CEO and chief medical officer of the Great Lakes Integrated Network, a New York-based physician network. “I think it is an exciting time. I know it is a lot of work.”
The Biden administration has made health equity a major pillar of its regulatory portfolio.
Next year will be the start of a new payment model that calls for not just the collection of health equity data to determine social risk factors, but also the implementation of solutions to address these problems. Providers that have been working on equity for years are lauding the decisions to move beyond planning and collecting data and into action.
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The ACO REACH payment model contains the first of such requirements. The voluntary payment model offers fully or partially capitated payments to physicians for meeting spending and quality targets.
In early 2023, participants will also have to submit to the Center for Medicare and Medicaid Innovation an equity plan, which is a totally new requirement for value-based care participants. The plan includes not only a requirement to collect data on social determinants of health for its patient population but also the development of measures to target these factors.
“The equity plan is nice and all, but we’ve had lots of people ask for plans over the years,” said Travis Broome, senior vice president for policy and economics for Aledade, which aids doctors in the transition to value-based care. “What REACH did is they put equity straight down to the bottom line.”
The equity plan itself can directly influence the benchmark that plans have to meet to qualify for shared savings. If a provider meets spending and quality targets, then it can get a share of any savings but must repay Medicare the difference.
The Centers for Medicare and Medicaid Services acknowledges “closing those gaps might be more resource-intensive than not closing them,” Broome told Fierce Healthcare in an interview. “That is the piece that I hope the industry takes from the REACH experience of not just saying have a plan but really moving equity into the actual design of the model itself. That is far more impactful in my view.”
ACO REACH participants are focusing on areas that frequently show up in patient screenings that are barriers to care such as transportation or stable housing.
Oak Street Health, a value-based primary care company, told Fierce Healthcare it has crafted wellness plans that address the needs of medically complex patient populations.
“Because of value-based care models like ACO REACH, where we’re responsible for the total cost of care, we are able to bring social workers and community health workers into the care team,” said Ali Khan, chief medical officer for Oak Street, in an e-mail to Fierce. “They work together to ensure that the patient and their caregivers are supported to achieve any actions assigned to them in the wellness plan, identify any wraparound services needed, and act as key partners to the broader clinical team.”
Aledade is also focusing on the social determinants of health that could impact high blood pressure. A key driver is to train more physician assistants and nurse practitioners to help in this area.
Broome said that a key issue during the creation of accountable care organizations (ACOs) under the Affordable Care Act is that you only get accountable care relationships with patients that see doctors, leaving out physician assistants and nurse practitioners.
For the Great Lakes Integrated Network, another key driver is improving health literacy and access.
“There are a significant number of patients who are not necessarily able to access healthcare but access other social services and have a need for healthcare,” Shields said.
The network is also partnering with community-based organizations that have access to primary care referral services, with the end goal to embed social work into the network’s approach to primary care.
ACO REACH’s equity plan may be the first concrete requirement for providers to create solutions but it likely won’t be the last.
CMS released an equity strategy back in April detailing how providers can identify and close gaps in care.
The agency has also included three equity-focused measures in the hospital quality programs as part of the inpatient payment rule back in August.
The measures focus on screening and creating a culture of equity. CMS has said they are interested in using measures to connect patients with social needs to community resources but has not finalized anything yet.
Payers moving into equity
Health insurance plans are expected to make more moves into health equity.
CMS proposed to start incorporating equity measures into the star ratings for Medicare Advantage and Part D plans in 2027. A plan’s star rating can affect the quality bonus that the insurer receives.
Commercial plans are also looking into private options to address equity.
Blue Cross Blue Shield of Massachusetts announced in December the first value-based contracts in the state that were tied to health equity. Blue Cross will offer financial incentives to four healthcare systems in the state to improve equity in several areas that include blood pressure control, colorectal cancer screenings and diabetes.
Health plans themselves are in a unique situation since they can see different patient populations to determine who may be missing preventive screenings or ensuring chronic conditions are being maintained, said RaeAnn Grossman, executive vice president of operations for Cotiviti, an analytics firm that works with health payers.
Plans are also exploring more holistic and fulsome onboarding assessments to understand why patients want to stay healthy and “what you need to maintain that health status,” she said. “We are seeing a lot of further dialogue between the health plan and their member earlier in the lifecycle of their membership.”