Improve Quality Metrics and Uplift Health Equity
Breaking down what health care companies can do to make health equity actionable and get ahead of the quality metrics curve.
June 2, 2022

The term ‘unprecedented times’ continues to describe 2022. Amid a global pandemic, ongoing racial reckoning and access to healthcare changes, the Biden Administration issued an Executive Order in January to advance racial equity across the US Government. This order triggered a cascade of actions centering equity and quality across government programs.

In mid-April the Department of Health & Human Services (HHS) released an Equity Action Plan to address inequities and advance “equity through assessing and changing policies, programs, and processes across the Department.” A week later, the Centers for Medicare & Medicaid Services (CMS) Office of Minority Health released the CMS Framework for Health Equity. CMS’ strategy is focused on identifying and responding to inequities in health outcomes, barriers to coverage and access to care. 

These plans are creating a foundation to address social drivers of health (SDoH) across government programs. In April, the Medicare Advantage 2023 Rate Announcement and 2023 Medicare Advantage and Part D Final Rule were published, as was the 2023 Final Rule for Qualified Health Plans (QHPs). Each of these announcements furthers the mission of the Administration to improve equitable care. 

Some notable highlights from the final rules that underpin the Administration’s commitment to equity:

  • data collection is critical to understanding the membership (i.e., expanded demographic information) and their needs (i.e., social determinants of health);
  • member input is invaluable to the plan and its’ operations (i.e., Special Needs Plans enrollee advisory committees);
  • Government plans must not simply collect information related to healthcare inequities but must act on that data (i.e., Quality Improvement Strategy Standards require issuers to address health care disparities).

At the same time, the National Committee for Quality Assurance (NCQA) released proposed updates and changes to HEDIS(R) measures for Measurement Year 2023 (MY2023). Some of these updates highlight the organization's focus on equity, including a proposed Social Need Screening and Intervention (SNS-E) measure and expanding the race and ethnicity stratification to at least 5 more measures across several domains. These proposed updates address both data collection and intervention on social needs.

The Medicare Advantage Announcement similarly proposed stratified reporting by disability, low-income subsidy status and dual eligibility status. CMS also proposed the development of a health equity index, summarizing performance into a single score within each contract and adding a Screening and Referral to Services for Social Needs measure to the Display Page. 

Localized Care

Standardized data collection, SDoH screening and measurement is essential to understand where our healthcare system stands in improving health equity and reducing disparities. The commitment to equity at the national level sets the stage for health plans to respond and to implement programs at the regional and local levels. 

Health plans and providers are tasked with Identifying and implementing programs to improve access, quality and outcomes for underserved populations; success locally requires improved relationships with the community, improved data sharing and improved digital partnerships.

With the end of the public health emergency (PHE), millions of Medicaid members will likely lose coverage. While access to ACA plan eligibility and enrollment is available, many individuals are unclear where to access this information. Government sponsored health plans can partner with their community providers, hospitals and community based organizations (CBOs) to ensure that individuals have questions answered relative to care and coverage. 

Medicaid eligibility determination often requires beneficiaries to take action to maintain coverage. Many individuals are unaware of this requirement. As we learned through the COVID pandemic, much can change in a year, including one’s mailing address, phone number or cell phone plan. Medicaid plans may send notifications in the mail to the wrong address or attempt to reach a phone that is out of order. Simply reaching members is a huge challenge and one that CBOs may be able to support. If a CBO is already working with an individual, it may be a helpful communication channel for plans, not only for enrollment but for understanding program availability. 

Interoperability & Digital Solutions

Knowing which health plans and plan programs (and/or SDoH interventions) are available and how to enroll in those programs is key in improving quality of care and outcomes. Participants in the healthcare system utilize multiple systems for capturing data around people and programs. There are numerous rules, laws and protections to ensure that individuals’ data is safe. 

As CBOs and digital health solutions have entered and flourished within healthcare, there is a growing need to connect their systems with provider and health plan systems. CBOs and digital health solutions alike can utilize HL7(R) and FHIR(R) API capabilities in accordance with the 21st Century Cures Act. APIs are essentially connections between computer systems/programs. These technical standards support communication between and among providers, practitioners and individuals seeking care.

To this end, the Centers for Medicare and Medicaid (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) require that individuals can access & control their own data. People must have access to their information, across systems (including electronic medical record, utilization management, etc). 

Beyond the technical underpinnings, CBOs and digital health solutions must be aligned with the goals of care delivery and services. Partnerships, as mentioned above, can effectively support individuals as they navigate social and medical programs. Mission alignment is essential between partners as alliances are formed and data sharing ensues. Programs and organizations who are taking action to improve equity are a good place to start. As ‘equity’ becomes common parlance, due diligence must be completed to understand which offerings are paying lip service to equity versus those who are “walking the talk.” Thankfully, with CMS and NCQA requirements in place, organizations are being held accountable to collecting, measuring and acting upon SDoH data.

Building an Equitable Quality Strategy

Quality improvement programs have long measured the effectiveness of care and services through NCQA and other measure stewards. Applying the equity lens to these programs requires a better understanding of how plans and providers perform when quality results are illustrated by race/ethnicity and other factors.

How will providers & plans collect race/ethnicity and other data without causing member abrasion or mis-trust? How will the healthcare system use the data? 

Some systems are incorporating new data fields within EMRs and health plan member eligibility databases to collect information on race, ethnicity and other socio-demographic factors. When individuals have access to these systems, they have the ability to update this information when/how they choose. Other organizations are asking, often for the first time, for individuals to self-identify race and ethnicity. These types of campaigns must include a component of “Why we ask” in order to help individuals trust the collection and use of that data.

As plans begin to collect SDoH data and screen for SDoH issues, organizations must ask themselves how they will use the data collected. This seemingly innocuous question will determine data structures required to house this information and how to share it appropriately. It will also serve as a message to plan membership as to “Why we ask”.

Who must you partner with in order to truly serve the individuals in your community? How can you utilize digital support to stay connected, improve access and reach?

Find the spaces and places that are supporting individuals in your locale today. If individuals already have relationships within the community, learn what is working, where the barriers to accessing care might exist and brainstorm (partner) to determine how the health plan or care provider(s) can help.

Robust data collection opens doors for digital platforms to create an engaging, equitable and accessible member experience and close care gaps created by previous systems.  Digital platforms can serve to collect data and allow individuals to take action by scheduling appointments, updating care plans and refilling prescriptions. Some organizations are offering wifi hotspots, member technical support, financial rewards and other means to bridge the divide that can be exacerbated by digital solutions.

For example, Wellth uses member data to individualize the member journey through specialized messaging, gamification, as well as access to live support. 

Check back with us for more information on proposed NCQA HEDIS(R) measures for 2023 and beyond to set you and your members up for success!