Addressing Health Care Disparities Using a Health Plan Quality Measures Index

ABSTRACT

Objectives: To develop an index using publicly available data to measure progress in addressing health care disparities.

Study Design: Given inherent socioeconomic differences between individuals insured by commercial/private insurance and those insured by Medicaid, we selected, based on set criteria, a portfolio of metrics comparing the national average performance between these 2 product lines from the Healthcare Effectiveness Data and Information Set (HEDIS).

Methods: Using data from the National Committee for Quality Assurance publicly reported national averages for HEDIS quality metrics from commercial/private insurance and Medicaid managed care, observed differences for these measures were aggregated to establish the index.

Results: The Health Insurance Disparities Index (HeIDI) demonstrated a gradual worsening of disparities nationally between individuals with commercial/private insurance and individuals with Medicaid insurance from 2017 to 2022, with a substantial deterioration during and after the COVID-19 pandemic years.

Conclusions: Because HeIDI assesses the status of health care disparities impacting individuals of lower socioeconomic status by insurance lines, it is useful for assessing performance for health plans, states, regions, and health systems utilizing verified HEDIS data.

Am J Manag Care. 2025;31(9):In Press

Takeaway Points

The Health Insurance Disparities Index (HeIDI) offers a relatively uncomplicated approach with validated and readily available public data for governmental/regulatory agencies, health policy researchers, states, health plans, and other stakeholders to detect trends in progress and identify workable interventions. We find that there has been a lack of progress in addressing these disparities of care nationally.

• Most reports on health care disparities are extensive, complicated, and unwieldy.
• HeIDI effectively tracks progress and may be used in policy assessments, program development, and value-based payment approaches.
• To date, nationally, there has been a regression in effectively addressing health care disparities.

The Robert Wood Johnson Foundation defines health equity as a state in which “everyone has a fair and just opportunity to be as healthy as possible.”¹ Measuring health equity should help reduce or remove differences in factors influencing health and outcomes, particularly those impacting marginalized or excluded groups.¹ Health care disparities are well documented across socioeconomic status, race, ethnicity, education, and place of residence.^2-4 COVID-19’s impact on minority and impoverished communities and public outrage over systemic racism in the US raised awareness of existing health care disparities.^5-8 Poverty, a major social determinant of health (SDOH), drives health care disparities in the US;⁹ 2019 US Department of Agriculture data show poverty rates notably higher across all racial and ethnic groups in rural areas (15.4%) compared with urban areas (11.9%),¹⁰ implying that health care disparities extend beyond just inner-city populations.

For more than 15 years, the Agency for Healthcare Research and Quality (AHRQ) has reported on health care quality and disparities,⁴ utilizing more than 250 measures from national data assessing structures, processes, and outcomes across health care settings. Some state initiatives¹¹ track indicators of racial and ethnic health care disparities. This preponderance of information can overwhelm organizations, hindering their ability to prioritize actionable steps. Organizations could benefit from more manageable data sets closely aligned with their organizational activities.

Health plans and health care systems are well positioned to identify improvement opportunities and influence narrowing of health care disparities. Unlike governmental agencies, health plans and health care systems face significant challenges in obtaining accurate data identifying individuals by race and ethnicity.¹² CMS acknowledges that reporting of race, ethnicity, language, disability status, and sexual orientation/gender identity remains inconsistent at best.¹³

Health plans and organizations serving socioeconomically disadvantaged populations (primarily Medicaid) could utilize a readily available set of publicly reported measures to assess health care disparities. This alternative could focus on improving care delivery for Medicaid enrollees relative to enrollees in commercial/private health plans. KFF data for 2022 reveal that 60.6% of Medicaid enrollees aged 0 to 64 years are non-White (Black, Hispanic, Asian/Native Hawaiian and Pacific Islander, American Indian, and multiple race) compared with 37.9% in employer/nongroup commercial/private plans (Table 1).¹⁴ Among those covered by commercial/private insurance, 58.9% have incomes at or above 400% of the federal poverty level, whereas only 10.5% of Medicaid enrollees fall into this income bracket. These statistics highlight a disproportionate enrollment of lower-income and minority racial/ethnic group individuals within Medicaid compared with commercial/private insurance. Medicaid patients with breast, colorectal, lung, or prostate cancers or non-Hodgkin lymphoma have significantly higher risks of dying within 5 years of diagnosis (ranging from 21% to 198% higher) than those who are commercially/privately insured.¹⁵

These findings support comparing quality of care delivered to enrollees in Medicaid managed care vs those in commercial/private managed care plans. Previous efforts highlighted disparities in health quality between these 2 insurance products using the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures.¹⁶ Other methodologies used diverse data sets to record performance among states, different plan ownerships, or specific plans.^17,18 Some initiatives have attempted to develop health care disparities indexes, including a summary index of several indicators,¹⁹ and another focused purely on the hospital environment.²⁰

Two reported efforts assessed health care disparities within Medicare Advantage. One study used a composite of 8 health behavior measures comparing outcomes between dually Medicare/Medicaid eligible White and Black members,²¹ whereas another approach stratified 12 measures of clinical quality and patient experience by race/ethnicity and dual-eligibility status, using these as a proxy for socioeconomic characteristics.²² Both approaches require accurate racial and ethnic data for effective analyses.

Our study proposes a simple method to measure health care disparities using a performance index based on nationally available HEDIS measures. This approach is a practical tool measuring disparities and identifying opportunities for improvement pending more comprehensive enrollee- and patient-level race, ethnicity, and income data becoming readily available and actionable for insurers and their health care delivery partners.

Measuring overall health status across a health plan’s entire membership presents challenges, especially in identifying meaningful and valid combinations of process and outcome measures to accurately assess performance. Our approach integrates a combination of processes and outcomes of care data empowering health plans, delivery systems, and other stakeholders to identify opportunity areas for improvement.

Quality of care delivered to commercially/privately insured vs Medicaid enrollees can differ for 2 main reasons: Enrollees in Medicaid face greater structural inequities from different SDOH, and differences exist in health plan characteristics, such as the breadth and quality of a health plan’s provider network. Our proposed index combines both these effects, capturing the full magnitude of the existing inequities. However, because health plans have greater control over plan-specific levers than structural factors, this index is more appropriate for surveillance and diagnostic purposes than for value-based reimbursement reward/penalty mechanisms, which would require risk adjustment to account for differences in enrollee characteristics. Our proposed index is most appropriate for the vast majority of health plans subject to the Affordable Care Act (ACA) requirement that preventive medical services be offered without any patient cost sharing, facilitating the receipt of services included in the index by enrollees in Medicaid and commercial/private plans.

METHODS

This study was exempt from institutional review board review because it utilized publicly available aggregated data for quality improvement purposes. The proposed Health Insurance Disparities Index (HeIDI) includes 39 health care–focused HEDIS measures. Currently, NCQA’s HEDIS data set, one of health care’s most widely used performance measurement and improvement tools, includes more than 200 million US enrollees.²³

After independent audit to ensure compliance with required measure data specifications, health plans report these measures to NCQA for plan accreditation, for Medicare payment incentives, and/or to meet state regulatory requirements. Consistent with NCQA’s categories of health plans, HeIDI focuses on comparing performance in the managed care realm between commercial/private health maintenance organization (HMO) plans and Medicaid HMO plans. HeIDI utilizes national averages from NCQA for measurement years 2017 through 2022.

CMS incorporates HEDIS measures into its Star Ratings system and for various Medicare quality, reporting, and payment programs.²⁴ States such as New York²⁵ and Massachusetts²⁶ publicly report the same or similar HEDIS measures for their value-based payment (VBP) or accountable care organization (ACO) initiatives. The National Quality Forum (NQF)²⁷ or its successors, the Partnership for Quality Measurement (PQM)²⁸ and the Core Quality Measures Collaborative (CQMC),²⁹ have endorsed many of these measures. NCQA requires HEDIS measures for its health plan accreditation and rankings programs for commercial/private and Medicaid plans^30,31 and has evaluated Medicaid’s use of quality measures to achieve equity goals.³²

HeIDI aims to empower state regulators, insurers, and care delivery entities such as health systems, ACOs, and physician practices to assess their progress in addressing health care disparities. Many participate in VBP programs utilizing selected HEDIS measures, routinely collecting performance data from VBP-contracted provider partners for these metrics. Given the relative ease of access to reported quality measure performance information and no extensive statistical analysis needed to produce HeIDI, this approach offers a useful and actionable tool for stakeholders.

Selection of appropriate measures that effectively capture and address disparities between individuals covered by commercial/private and Medicaid plans was critical in developing HeIDI. HEDIS measures have uniform data specifications, are audited annually, and are reported for both insurance types. Selected measures needed to be recognized by reputable national endorsing entities as being important for disparities measurement and substantially utilized by states with Medicaid managed care programs.

NCQA’s HEDIS measures for its accreditation programs and health plan rankings for both commercial and Medicaid plans^30,31 are reported annually for both product types. CMS establishes Child and Adult Core Sets of health care quality measures for Medicaid,²⁴ whereas NQF previously identified a Disparities-Sensitive Measures Set.²⁷ CQMC has developed its own Consensus Core Sets²⁹ as well. The programs of the 20 states that account for the vast majority of Medicaid managed care enrollment (54.5 million of the total 66 million individuals) in Medicaid managed care across 42 states (82.5% of all Medicaid managed care enrollees) were reviewed to assess the extent of utilization of these measures for VBP and/or public reporting.

For a quality measure to be included in HeIDI, the selection criteria are as follows:

• A measure used for public performance reporting and/or in VBP quality programs impacting at least 50% of state Medicaid managed care organization (MCO) program enrollees nationally is automatically included as a HeIDI measure.
• A measure endorsed by more than 2 nationally recognized authoritative entities (NCQA, CMS, NQF, or CQMC) as a disparities measure and/or for public reporting is designated as a HeIDI measure.
• A measure used for public performance reporting and/or in VBP quality programs impacting more than 30% but less than 50% of state Medicaid MCO program enrollees nationally is considered equivalent to 1 certified entity endorsement as allowed in the second criterion above.

For NCQA’s health plan accreditation and health plan rankings programs,^30,31 process measures receive a relative weight of 1, whereas outcome and high-priority process measures (per NCQA) receive a relative weight of 3. HeIDI embraced this measure weighting approach. Table 2²³ lists each measure in the HeIDI index, along with its assigned weight and whether the measure is subject to the ACA’s prohibition of patient cost sharing for preventive services, including the sponsoring regulatory and/or guideline authority, professional organization, or guideline entity deeming the importance of the measure. eAppendix 1 (eAppendices available at ajmc.com) additionally details how each measure met the selection criteria, identifying which national authoritative entities provided endorsement and which states utilize a given measure with its associated national percentage of use.^33,34 This portfolio of measures consists of 24 physical medicine measures and 15 behavioral health (BH) measures, totaling 39 measures from NCQA’s HEDIS 96-measure data set spanning 6 domains of care.

HeIDI measures represent child/adolescent care; BH care; women’s health care; adult care; and care for chronic conditions such as diabetes, respiratory diseases, and cardiovascular conditions. Each measure is annually reported to NCQA for both commercial/private and Medicaid managed care plans. Prior to measurement year 2023, colorectal cancer screening, an important measure, was nationally reported only by commercial/private plans (not by Medicaid plans) to NCQA, so it is not included in the current HeIDI measurement set. Newly implemented and reported measures meeting HeIDI selection criteria will be added after an established record of reporting and reliability.

Some states carve out BH services from the Medicaid health plan’s benefit package. To address this, the HeIDI non-BH (NBH) version excludes the 15 BH measures from the index, offering the option for a more comparable assessment when analyzing organizations across states or regions with different Medicaid BH benefit packages.

Data utilized for HeIDI originate from publicly reported and available sources, including NCQA’s website²³ for national HEDIS performance results (measurement years 2017-2022), NCQA’s Quality Compass licensed database, and state-provided public reporting websites.³⁵ NCQA’s website compiles results and reports national averages by product line, eliminating the need for modifications or changes to HEDIS measurement specifications beyond what NCQA performs for its reporting.

HeIDI compares the performance on each measure between commercial/private HMOs and Medicaid HMOs using NCQA-reported national averages for each product line. If the performance difference between the 2 favors commercial/private plans over Medicaid plans for a given metric, that difference serves as the score indicating a disparity. For measures assigned a relative weight of 3 in HeIDI (and by NCQA), any disparities identified are multiplied by 3.

HeIDI aligns with the World Health Organization’s principle of reducing systematic differences in health between different socioeconomic groups, in which “the ultimate vision is to eliminate such inequities by raising health outcomes to the level of the most advantaged group.”³⁶ Consequently, HeIDI calculations offer no “extra credit” for measures where the Medicaid product outperforms the commercial product. Thus, the disparity is set to zero rather than a negative number.

To compute the HeIDI score for a given year, the differences in performance for each measure are appropriately weighted and summed up to form a difference (gap) numerator value. This value is then divided by the denominator of the weighted sum of the commercial/private product’s performance rates for all measures (Table 3). The HeIDI score is essentially the percentage-point difference in the quality of care received by Medicaid enrollees relative to commercial enrollees. A perfect HeIDI score, indicating that disparities relative to Medicaid have been effectively addressed and parity achieved, would equal zero. Scores greater than zero indicate the aggregate presence of health care disparities for Medicaid managed care enrollees.

Thus, HeIDI tracks progress in addressing disparities impacting Medicaid enrollees nationally while supporting comparisons for which statewide or individual health plan data are accessible from either Quality Compass or the state.

To currently evaluate how commercial/private and Medicaid product lines fared independently in meeting the 39 selected measures for the HeIDI index, data from 2017 through 2022 were aggregated for each product line. Each year’s total possible points and actual points achieved by product lines were recorded, along with the percentage relative to the maximum potential score (HEDIS performance data are found in eAppendix 2). For this analysis, Medicaid plans received credit when their performance exceeded that of the commercial/private plans for a particular measure, although in using the HeIDI tool, Medicaid plans do not.

RESULTS

As depicted in Figure 1,²³ the commercial/private product line reached 58.1% in achieving perfect HEDIS scores in 2022, whereas Medicaid was lower at 52.4%, indicating that nationally, regardless of product line, there is still considerable opportunity to improve health care delivery reflected by the HeIDI HEDIS measures. Unlike the HeIDI results reported below, the 5.7–percentage point difference in Figure 1 does give Medicaid plans credit when they outperform commercial plans on a specific measure.

In applying HeIDI using national data (2017 through 2022) using the averages for commercial/private HMOs against the averages for Medicaid HMOs (Figure 2²³), one discovers a growing disparities gap of 3.25 points year over year from 2017 through 2022, with a marked worsening from 2020 onward of nearly 2 points in HeIDI nationally between these insurance programs (computation of HeIDI values is found in eAppendix 3). Similarly, the NBH HeIDI experienced a parallel change across the 6 measurement years, with an observed erosion nationally from 2017 onward of 4.45 points in the index score. The goal would be to achieve a value of zero for HeIDI and NBH HeIDI, indicating that Medicaid enrollees are receiving health care quality at the same level as enrollees in commercial/private plans. This is certainly not the case.

In eAppendix 4, we report HeIDI scores when we increase the third inclusion criterion from the range of more than 30% to less than 50% of state Medicaid MCO program enrollees nationally using a measure to a range of more than 40% to 50%. The results are similar. In eAppendix 5, we report HeIDI scores using all measures, including those for which Medicaid plans outperform commercial plans and receive extra credit. The results are qualitatively similar.

DISCUSSION

Addressing US health care disparities is like managing a complex, poorly understood, and difficult-to-treat chronic disease. Underlying sources are diverse, including widespread poverty, embedded racism within the health care system, SDOH, variations in health care financing and coverage, disparities in access to care, practitioner training, understanding of public health issues, and health care delivery system design and operations including cultural competency gaps. Although this problem lacks simple or quick solutions, it presents opportunities for health care stakeholders to reexamine their respective roles, identify underlying issues, and develop interventions to advance health care equity.

As the analysis using HeIDI shows, the gap in health care disparities continues to worsen, indicating that more work needs to be done. The COVID-19 pandemic impacted health care workforce staffing, resulting in reduced access to health care services overall,³⁷ which probably contributed to the worsening in index scores from 2020 onward. CMS and others are also concerned that the expanded use of virtual and telemedicine services during the pandemic widened health inequities, specifically for low-income or working poor individuals, and rural populations that generally have less access to these services than those from higher socioeconomic backgrounds.^38-41

The federal government and many states have conducted numerous studies publicly reporting the status of health care disparities, which might be unwieldly and not actionable without extensive further analysis. To mitigate this, the HeIDI scoring system is a tool that health plans, states, care delivery systems, researchers, and others can use to track progress in managing disparities and identify the greatest opportunities for improvement. HeIDI leverages readily available, publicly reported information for a large number of process and outcome measures that do not require extensive statistical and analytical expertise, thus offering a practical means for health care stakeholders to assess the progress of their efforts to address disparities. The strength of this new index is that it captures the full magnitude of the inequality in care between socioeconomically disadvantaged and advantaged individuals. The weakness is that health plans and providers acting unilaterally can only readily address some of the factors creating inequities. Therefore, this index would be most valuable when used in conjunction with measures that compare quality of care within the same plan, or same type of plan, for disadvantaged vs advantaged groups.^42,43

Additionally, HeIDI can support health systems researchers in exploring various underlying variables contributing to the performance of an entity (such as states, health plans, delivery systems), including the impact of carved-out services, health plan size, tax status of organizations, state eligibility rules, benefits provided, waiver programs, financial incentives, implementation of alternative payment mechanisms, existence of sister commercial/private plans alongside Medicaid, and regional characteristics.

The HeIDI NBH tool comparably analyzes the performance of BH carve-out plans against those plans that provide BH services benefits. With growing support for integrating physical health services and BH services into whole-person care,^13,44-47 until such integration becomes standard practice nationally, the HeIDI NBH scoring tool allows measurement of health insurance disparities adjusting for this.

Limitations

Although HeIDI may be impacted by updates implemented by the various stewards and developers of these measures, including NCQA, states, CMS, PQM, CQMC, and other national entities,³³ such changes in data specifications and measures typically apply across all health plan product lines, thereby minimizing this impact on comparisons. Should any measure be retired, other measures meeting inclusion criteria will be considered as replacements without significantly impacting the tool’s integrity.

CONCLUSIONS

HeIDI is a practical tool for assessing progress in addressing and eliminating health care disparities across different insurance product lines. By measuring performance disparities, it can help identify where attention is needed to implement changes that improve and promote equitable care, regardless of the insurance product enrollment. With the worsening of health care disparities as spotlighted by HeIDI, determining effective interventions remains a pressing challenge for all stakeholders committed to addressing this critical issue in our health care system and society.

Acknowledgments

The authors wish to thank Caroline N. Stankaitis, DPT, and Peter Coyle, PhD, for their feedback on an earlier version of this paper.

The primary source for data contained in this publication is NCQA’s publicly accessible website titled “HEDIS Measures and Technical Resources” for HEDIS measurement years 2017 through 2022. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA holds no responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. HEDIS is a registered trademark of NCQA.

Author Affiliations: Sloan Program in Health Administration, Cornell University Brooks School of Public Policy (JAS, SS, SN), Ithaca, NY; Department of Economics, Cornell University (SN), Ithaca, NY.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JAS, SN); acquisition of data (JAS); analysis and interpretation of data (JAS, SS, SN); drafting of the manuscript (JAS, SS, SN); critical revision of the manuscript for important intellectual content (JAS, SS); and administrative, technical, or logistic support (JAS).

Address Correspondence to: Joseph A. Stankaitis, MD, MPH, Cornell University Brooks School of Public Policy, 24 Hiram Way, Honeoye Falls, NY 14472. Email: jas2242@cornell.edu.

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