II. Closing the Health Equity Gap in CMS Hospital Quality Programs—Request for Information
Key comments:

To reduce health inequities among Medicare beneficiaries, CMS should support ACOs’ work to target outreach and address the complex needs of underserved populations. ACOs need appropriate tools, data, financial incentives, and resources to address health equity issues and develop partnerships with community organizations. To do so, CMS should implement these recommendations:

NAACOS appreciates the opportunity to submit comments on how to make reporting of health inequities based on social risk factors more comprehensive and actionable. Like CMS, NAACOS is committed to reducing health disparities, and we aim to support ACOs in their efforts to improve and maintain the health of populations and reduce gaps in health equity by addressing social needs and social drivers of health. We strongly support the use of data to target interventions toward populations and individuals in need. 

Strengthening ACO and other total cost of care models provides an important opportunity to reduce health inequities and transition our health system to a culture of value. Improving health equity is critical to delivering high quality care in a cost-effective manner and focusing on the broader concept of an individual’s overall health, as social drivers of health contribute significantly to achieving better health outcomes. These social factors cannot be addressed if they are not adequately identified, measured, tracked, and reported. 

Many ACOs have been doing important work to address social needs and inequities among their patient populations. Financial incentives related to improving quality performance can be targeted to providers serving large proportions of minority and vulnerable populations, thus reducing inequities. Studies have shown that ACOs are increasingly working to address patients’ nonmedical needs to improve their health, such as partnering with other organizations in the community to meet housing and transportation needs and address food insecurity.^v  Some specific examples of ACO initiatives to address health equity include:

To continue and build upon these activities, ACOs need appropriate tools, data, financial incentives, and resources to address health equity and develop partnerships with community organizations. To do so, CMS should implement the recommendations below.

1. Create new opportunities for ACOs to address health equity

Provide additional flexibility with Medicare rules for providers to deliver supplemental benefits to patients to help address health equity issues:

In order for ACOs to be able to test innovative approaches to improving health equity, additional flexibility with Medicare rules for providers to deliver supplemental benefits to patients is necessary. 

For example, this memo^vi shares information on flexibility for providing transportation to patients. NAACOS was very pleased to see this guidance from the Department of Health and Human Services (HHS) Office of Inspector General, providing flexibility from the federal healthcare program anti-kickback statute. We recommend HHS and CMS provide additional flexibilities to allow ACOs to deliver other benefits such as those related to housing or food insecurity. 

There is precedent in Medicare for allowing such flexibilities, recently illustrated by new policies in Medicare Advantage (MA) that allow premium dollars to go towards addressing social needs. The Bipartisan Budget Act of 2018 expanded the types of benefits that may be offered by MA plans for chronically ill patients.^vii These supplemental benefits may include things like meals, food and produce, transportation for non-medical needs, pest control, indoor air quality equipment, social needs, complementary therapies, structural home modifications, services supporting self-direction, and/or general supports for living. Because ACOs are accountable for the total health outcomes of the populations they serve and total cost of care, they should be allowed similar flexibilities in how they allocate resources to meet the needs of a certain population. 

Provide funding to ACOs to support expanding social services to address health equity issues:

As reflected in the examples above, many ACOs already have initiatives to address health equity and other ACOs are in the process of planning to introduce similar initiatives. However, financial barriers and resource constraints remain a major hurdle to this work. Without additional funding and incentives to do this important work, true progress will not be realized. 

One option to address this would be for CMS to provide grants to ACOs to expand their connections with community-based organizations (CBOs) and to enhance ACOs’ internal capacity to deliver health services and meet social needs. Additionally, the Center for Medicare and Medicaid Innovation (CMMI) could establish a voluntary model for MSSP ACOs focused on addressing health equity. ACOs would detail to CMMI how they would use upfront funding to address health equity gaps among their patient population. If the ACO generates shared savings, the initial investment could be recouped by CMS, and if it does not generate savings, the funds would be forgiven by CMS as long as the ACO remains in the program. This model would be similar in design to the Community Health and Rural Transformation (CHART) Model, which builds off the ACO Investment Model that was one of the most successful CMMI models to date. 2. Ensure quality reporting is thoughtfully designed and implemented to avoid penalizing ACOs treating patient populations struggling with health inequities.

Recent changes to the way ACOs are required to measure and report on quality, finalized in the 2021 Medicare Physician Fee Schedule Rule (CMS-1734-P), may have inadvertent negative impacts on health equity. The rushed implementation of the MSSP quality overhaul has resulted in many unanswered questions about how to satisfy the new requirements for reporting all-payer data and electronic Clinical Quality Measures (eCQMs) and Merit-based Incentive Payment System Clinical Quality Measures Clinical Quality Measures (MIPS CQMs).  The lack of standardization across electronic health records (EHRs) will cause significant administrative burden and high costs, which will direct resources away from patient care and equity interventions.  This burden comes at a time when ACOs are struggling to deal with the COVID-19 pandemic and related impacts.  Additionally, requiring ACOs to report on all patients across all payers rather than just ACO-assigned Medicare beneficiaries may adversely affect ACO practices treating vulnerable populations, such as those with high rates of Medicaid and uninsured patients. For example, many ACOs have relationships with Federally Qualified Health Centers (FQHCs) to provide care to their assigned beneficiaries. Differences in the medical complexity, social needs, or other factors in these populations will skew performance on quality measures and penalize ACOs and ACO practices treating more vulnerable populations at a time when they need the resources the most.

In order to avoid these potentially negative impacts to patient care and health equity, NAACOS makes the following recommendations:

NAACOS has highlighted these recommendations and others with additional detail on unanswered questions and concerns in a letter^viii to HHS Secretary Becerra in May.  We encourage these changes be made quickly to ensure that ACOs can equitably and effectively serve their assigned populations.

3. Leverage the ACO model to test expansions in telehealth for the ability to improve access and quality while controlling costs

In the wake of the COVID-19 pandemic, ACOs were able to quickly pivot to telehealth and remote patient monitoring to meet the needs of their patients in a safe and accessible manner. Virtual care has provided unprecedented access for patients, but it has become clear that uncertainty as to the future of telehealth under Medicare will halt or reverse further adoption and utilization—to the detriment of both patients and providers. While the digital divide remains an issue for patients without access to reliable broadband services, telehealth has greatly expanded access to primary and specialty care for patients in rural areas with limited access to services. 

NAACOS supports broader telehealth coverage and wants to see many of the flexibilities granted during the COVID-19 pandemic be made permanent; however, there are concerns about potential adverse effects on spending and ACO attribution. To ensure that telehealth is expanded in a cost-effective manner that ensures the continued delivery of high-quality care and does not disrupt ongoing patient-provider relationships, we recommend ACOs and other APMs be used to test broader reforms.  To prevent a disruption in care continuity, incentives should be provided to have care delivered in virtually integrated practices as part of an ongoing comprehensive care strategy. Deference should be given to Medicare providers who are accountable for patients’ spending, quality, and health outcomes, such as ACOs. 4. Lift 42 CFR Part 2 restrictions to support care coordination and improve patient care

NAACOS continues to call for the alignment of 42 CFR Part 2 (Part 2), which governs patient substance abuse treatment records, with the Health Insurance Portability and Accountability Act (HIPAA). This alignment will improve care coordination and quality improvement and allow ACOs and other providers to deliver the kind of patient-centered, well-coordinated care necessary to improve health outcomes and reduce inequities. While substance use disorder (SUD) affects all racial and ethnic groups, Black and Latinx Americans are less likely to complete treatment for SUD.^ix By equipping providers with the necessary information for coordinated, whole-person care, these disparities can begin to be addressed.  

Currently, ACOs lack access to the full suite of necessary information to allow them to achieve the goals of well-coordinated patient care, improved quality, and preventive care required to limit opioid overdose deaths and other adverse events associated with SUD.  While ACOs are provided claims data through Claim and Claim Line Feed (CCLF) files, these data lack SUD-related information, thus limiting ACOs’ ability to treat the whole person and potentially harming patient care and outcomes. While Section 3221 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act helped to align Part 2 with HIPAA by allowing the sharing of this important data after initial patient consent, implementation has been challenging. NAACOS asserts^x that current regulations allow CMS to deliver unredacted claims data to ACOs. We urge^xi you to work with your HHS partners to send SUD-related claims data to providers practicing in APMs to help support their work in population health management and SUD-focused initiatives. 

As mentioned previously, many ACOs are implementing new initiatives to address health inequities, but these programs cannot effectively reach the right patients if ACOs do not have the appropriate data to target outreach to vulnerable populations.