NAACOS White Paper: CMS Must Make Changes In Order to Advance Health Equity
The leaders of NAACOS, the National Association of ACOs, on Oct. 25 published a white paper in which they made recommendations on how the Medicare program can improve equity in health outcomes using the quality requirements in accountable care organizations.
As the NAACOS leaders noted in a press release published on Monday, “As part of all its ACO programs, the Centers for Medicare and Medicaid Services (CMS) evaluates ACOs on a number of quality measures, such as uses of preventive screening tools and hospital readmissions. But current quality evaluations could be updated to improve health inequity, and the NAACOS paper offers seven concrete recommendations for making that happen. NAACOS had previously published a white paper on better positioning ACOs to address health inequity and social determinants of health (SDOH). These recommendations must be done in a step-wise and thoughtful manner and with the support ACOs need to be successful in these efforts.”
As noted in the press release, the recommendations made in the white paper, entitled “Addressing Equity in Quality Measurement for ACOs,” are:
> Begin collecting race and ethnicity data in a standardized way to help the deployment of more targeted care coordination and improvement strategies to close equity gaps.
> Adjust patient survey data to begin incorporating equity questions, such as adding a question focused on receiving timely access and culturally appropriate care.
> Incentivize ACOs’ use of SDOH screening tools of the ACO’s choosing.
> Identify a subset of ACO quality measures that could be stratified by race and ethnicity.
> Consider providing incentives for improving quality scores for subpopulations identified as having lower performance based on race and ethnicity categorizations.
> Develop and incorporate into ACO programs quality measures that address health equity at the population-health level.
> Avoid making adjustment to quality benchmarks for race and ethnicity.
"Improving health equity is critical to delivering high-quality care in a cost-effective manner, as some research shows that social drivers of health contribute more significantly to health outcomes than medical care," the paper stated. "Social risks and social needs cannot be addressed if they are not adequately measured, tracked, and reported."
And the press release quoted Clif Gaus, Sc.D., NAACOS president and CEO, in a statement in which he said that "ACOs today are already required to collect and report on lots of data points on how they treat their patients. These requirements can easily be updated to better address health equity. Our recommendations are another example of how CMS can leverage ACOs today to achieve the agency’s top administrative priority of improving equity."
Early on, the white paper makes the point that “Total cost of care models, such as accountable care organizations (ACOs), are incentivized to improve quality while controlling costs, and the upfront investments that ACOs make in health information technology (IT) and infrastructure to provide coordinated care make them uniquely poised to address health inequities. The National Association of ACOs (NAACOS) is the largest association of ACOs and Direct Contracting Entities (DCEs) representing more than 12 million beneficiary lives through hundreds of Medicare Shared Savings Program (MSSP), Next Generation ACO Model, Global and Professional Direct Contracting Model (GPDC), and commercial ACOs. NAACOS is a member-led and member-owned nonprofit organization that works on behalf of ACOs and DCEs across the nation to improve the quality of Medicare delivery, population health, patient outcomes, and healthcare cost efficiency. NAACOS is committed to advancing the value-based care movement and our members want to see an effective, coordinated, patient-centric healthcare system that focuses on keeping all individuals healthy. Strengthening the ACO model and other total cost of care models provides an important lever by which health inequities can be reduced.”
What’s more, the paper states, “Improving health equity is critical to delivering high quality care in a cost effective manner, as some research shows that social drivers of health contribute more significantly to health outcomes than medical care. Social risks and social needs cannot be addressed if they are not adequately measured, tracked, and reported. Innovative payment and care delivery models that rely on data provide an opportunity to better understand and highlight existing disparities and the tools to tailor interventions based on individual need. For example, ACOs assume accountability for a population’s cost and quality of care, and many are beginning to address patients’ social needs such as housing, transportation, and food insecurity as a way to improve health outcomes.”
The paper goes on to state that “One important way to support ACOs in addressing health equity is through quality measurement at the population health or ACO level. There are many quality measures which the Centers for Medicare & Medicaid Services (CMS) currently considers to be "topped out," meaning performance is high among most reporting the measures, however, these measures may show additional room for improvement when stratified by social risk factors such as income level, as an example. Stratifying quality measures by social risk factors may allow ACOs to target tailored interventions designed to have the most meaningful impact on underserved populations. In this way, ACOs can address health inequities existing within their patient populations. These efforts to address health inequities through quality measurement must be coupled with other efforts to support ACOs in addressing health equity. Equity initiatives require significant upfront investment to be effective, and, therefore, ACOs require additional flexibility and resources to be able to address these concerns with their patient populations.”
And, under the recommendation “Stratify a Subset of Quality measures by Race/Ethnicity,” the white paper notes that “The National Committee for Quality Assurance (NCQA) has begun to stratify a subset of quality measures by race and ethnicity to identify areas of improvement. CMS should begin to identify a subset of ACO quality measures that could be stratified by race and ethnicity. In order to do this successfully, however, there first must be accurate and complete data on race and ethnicity available to ACOs. CMS could also look to the Health Resources and Services Administration (HRSA) efforts in this space, as Federally Qualified Health Centers (FQHCs) are currently required to report data in this manner as part of the Uniform Data System (UDS) Resources Requirements.”
At the end of the document, the white paper concludes with the following: “Social factors and systemic discrimination have led to wide and longstanding gaps in health equity for underserved communities. Improving health equity is critical to delivering high quality care in a cost-effective manner, as some research shows that social drivers of health contribute more significantly to health outcomes than medical care. These social factors cannot be addressed if they are not adequately measured, tracked, and reported. Policy solutions that rely on data provide an opportunity to better understand and highlight existing disparities and provide the opportunities to tailor interventions based on individual needs. Total cost of care models such as ACOs are incentivized to improve quality while controlling costs, and the upfront investments that ACOs make in health IT and infrastructure to provide coordinated care make them uniquely poised to address health inequities. The above policy recommendations will allow ACOs to advance quality improvement for the underserved. However, ACOs cannot begin to do this work without also providing the tools and resources needed to implement and deploy interventions to reduce these inequities and to improve patient care for underserved populations. NAACOS has also provided CMS with additional policy recommendations for program design modifications to achieve these goals.”
The entire text of the white paper can be found here.
