Health Equity

Stratified Reporting
NAACOS applauds CMS’s work to stratify quality measures by certain SRFs to identify gaps in quality performance within contracts. CMS currently stratifies a set of clinical care measures by race, ethnicity, gender, rural/urban status, low-income status (LIS), dual-eligibility status, disability status, and age group, and additionally stratifies a small set of patient experience measures by race, ethnicity, and gender for Part C. This is an important step in the effort to close health equity gaps and we encourage CMS to stratify quality measures for providers in other programs such as APMs. NAACOS recommends CMS explore other variables for stratification such as language spoken at home, LGBTQ identity, and education level, to determine what combination of variables provides the most actionable data and is representative of diverse populations’ experiences. 

Health Equity Index
CMS notes the agency is developing a health equity index as a methodological enhancement to the Star Ratings that summarizes contract performance among those with SRFs across multiple measures into a single score. While NAACOS is supportive of the goal to incentivize plan sponsors to reduce disparities through care improvements and evidence-based interventions for higher-risk beneficiaries, it is concerning that CMS notes that current available data to use for the index include only disability and LIS/DE. There is mixed evidence on these variables as effective indicators for health equity, with recent evidence that dual eligibility is an insufficient proxy for social risk, obscuring important SRFs affecting duals disparately.^[6],^[7] Given state-by-state differences in Medicaid eligibility criteria, you cannot accurately compare dual-eligible beneficiaries nationally.^[8] It is clear that a more nuanced approach is needed to adequately account for social risk. Before developing a health equity index, CMS should explore other variables to include and pursue strategies to improve data collection on important demographic factors that contribute to health disparities such as race, ethnicity, language, and gender identity. These strategies should include communication and education efforts to build trust with beneficiaries, as many may be hesitant to report this data because of the history of healthcare discrimination against racial/ethnic minorities and women.^[9] NAACOS also urges CMS to collaborate with stakeholders to create data collection and reporting processes that result in accurate and actionable data without placing undue burden on providers. 

Measure of Contracts’ Assessment of Beneficiary Needs
NAACOS supports the efforts of CMS to increase standardized screening for HRSNs and SRFs, and we recommend developing positive incentives for providers to conduct these screenings effectively and efficiently. In order to meet diverse practice and provider needs, there is a need for flexibility in choosing which screening tool to use, as long as it meets basic standards. CMS should work to publish guidelines to help providers choose the right screening tool, as well as educational materials to train providers on how to ask screening questions in a manner that encourages honest and accurate responses from patients, and how to communicate to patients how the information will be used. We encourage the agency to avoid implementing overly burdensome requirements or too many measures, which would limit uptake and contribute to provider burnout. It is also important to consider the broader health system and collaborate with other payers to ensure cross-payer alignment that will support an overall shift to a more equitable health system. 

Screening and Referral to Services for Social Needs
As referenced above, NAACOS encourages CMS consider proper incentives, reasonable flexibility, and cross-payer alignment when developing social risk screening requirements. Incorporating referral to intervention adds another layer of complexity and CMS should recognize the additional time and resources required to develop relationships with social services and community-based organizations (CBOs), as well as the costs associated with the information technology infrastructure necessary for a closed-loop referral system. Many CBOs are underfunded and may not be able to handle the additional capacity to meet the increased demand generated by these referrals. CMS should solicit detailed feedback from CBOs, small and/or rural providers, and other relevant stakeholders in order to understand these challenges before considering this type of measure.