Contributor: Navigating Health Equity in 2024: The Evolution of Accountability, Part 1

This article is part 1 of 2. Read the second part here.

Payers, health systems, and health professionals will experience expanded accountability for performance in closing health disparity gaps in 2024. With advances in public health research, many modern health challenges have been attributed to how social and ecological factors, commonly referred to as social determinants of health (SDOH), can influence health outcomes. To measure the progress in achieving health equity, health disparities are used as a metric to further understand the health ecosystem and the complex dynamics that influence health.

The year 2024 will be the first full year in which health systems will be held accountable by The Joint Commission (TJC) for performance on their National Patient Safety Goal to improve health care equity.¹ The National Committee for Quality Assurance (NCQA) has expanded race and ethnicity stratification to 9 additional Healthcare Effectiveness Data and Information Set (HEDIS) measures in the measurement year 2024, holding plans and ultimately their participating hospital and practitioner networks accountable for performance on 22 stratified measures within its measure set.²

This article (parts 1 and 2) discusses the importance of SDOH in the health ecosystem; examines the impact of standardized measures in regulatory settings; reviews current, relevant quality measures pertinent to hospitals and health plans; and suggests resources and steps stakeholders (eg, plans, health systems, pharmacists, life science companies) can leverage to incorporate SDOH and health equity initiatives into systemic practice.

Why Are Measures Important in SDOH?

Although there have been significant investments to improve health care outcomes, more than one-third of American families continue to struggle with affording housing, food, transportation, and other support needs.³ Although clinical care advancements are essential for improving health outcomes, SDOH can also significantly affect a population’s health, functioning, and quality of life. Therefore, addressing the health equity challenges associated with them is essential for making progress toward attaining high-quality health care. Achieving greater health equity requires communication and coordination between a variety of parties that depict the ecosystem of factors that add to the health outcomes patients face. Such parties include, but are not limited to, the government, health care practitioners, hospitals and health systems, health plans, community organizations, and private sector partners such as life science companies.

SDOH quality measures are indicators used to assess and understand the various factors that can influence individuals’ and populations’ health outcomes.⁴ These measures are used to help health care providers and quality and population health leaders evaluate and minimize disparities by gaining a comprehensive understanding of factors that are potentially contributing to identified health inequities and developing interventions to address them. Examining how health and SDOH issues overlap in different communities can be pivotal for promoting public health, prevention, treatment, and population health management, which refers to the act of improving clinical health outcomes for a priority population through coordination and engagement supported by financial and care models.⁵

Health equity measures apply to all health systems due to the significant recognition and knowledge of health disparities in health care practice, but solutions to alleviate these disparities are still evolving. To combat low health outcomes, different health care organizations must establish new quality measures to identify and address these needs. Additionally, it is important to recognize the role that pharmaceutical and pharmacy sectors have with other stakeholders due to the development and distribution of drugs. Biases within these industries are seen with the types of treatments being researched and the communities included in clinical trials.⁶ With measures, we can focus efforts to overcome implicit bias with organizational support, educational resources, and training skills. Overall, SDOH can help providers reach a holistic and effective approach to working toward a healthier society.

Current SDOH and Health Equity Measures

Current quality measures that are being used by providers and stakeholders include, but are not limited to CMS SDOH measures for hospitals and the NCQA’s HEDIS, one of the most-used quality performance tools by health plans.

CMS Equity-Focused Process Measures

The measure set adopted by CMS was proposed by The Physicians Foundation, which prioritizes implementing measures to depict social and economic determinants and requires hospitals in federal payment programs to report what portion of their population is screened for SDOH (SDOH-1), as well as how many screen positive in each category (SDOH-2). The 2 measures being scored, SDOH-1, Screening for Social Drivers of Health, and SDOH-2, Screen Positive Rate for Social Drivers of Health, are both process measures with specific patient populations.⁷ The 5 specific social needs for screening are food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. The goal of these measures is to have all hospitals collect patient-level social risk factor data and use these data to stratify patient risk and hospital performance rates. Starting January 2024, health care organizations are required to report SDOH measures to CMS in the inpatient sphere by May 15, 2025.

Healthcare Effectiveness Data and Information Set

HEDIS is a tool from the NCQA used by over 90% of health plans in the US to measure performance and make comparisons among different health plans.⁸ The NCQA’s goal is to improve health outcomes by providing standardized metrics as a means to benchmark the health care quality provided while promoting transparency and quality improvement efforts.

As previously mentioned, the NCQA will be expanding HEDIS by adding stratification by race and ethnicity to 9 existing measures, for a total of 22 measures stratified by race and ethnicity in 2024. By stratifying measures by race and ethnicity, advocates can further understand racial and ethnic disparities in care and learn how to address care gaps by holding health plans accountable for addressing these disparities.⁹ Some HEDIS measures selected for stratification include controlling high blood pressure, glycemic assessment status, pharmacotherapy for opioid use disorder, and prenatal and postpartum care.

The NCQA is also expanding its measures reported using Electronic Clinical Data Systems (ECDS), and measures selected for stratification by race and ethnicity include colorectal cancer screening, prenatal depression and postpartum depression screening and follow-up, and immunization measures. Although not presently stratified by race and ethnicity, also included within the ECDS measures is assessing plan performance on screening and intervening in SDOH, with a particular focus on social needs related to food, housing, and transportation.

The measures considered for stratification have been evaluated based on the use of the measure across multiple plans, such as Medicare and Medicaid; the degree to which the health condition has been prioritized; and the extent of known disparities by race and ethnicity.¹⁰ Noting that race is a social, not a biological construct, the NCQA has indicated that data collected are not to be used to create additional bias; nor are they meant to convey that race and ethnicity are biological determinants of health. Rather, the stated intent is to hold entities accountable to identify and address disparities.² With this collected information, more organizations will be prepared to provide equitable care with an understanding of the populations and communities being served.

Impact of Standardized Measures in Regulatory Settings

Effective action for achieving health equity is seen through regulatory and standardized measures. Several hospital regulatory bodies, such as TJC and CMS, have published new health equity requirements and measures that have already been or will be launched in 2023.¹¹

Standard LD.04.03.08 established by TJC, which addresses health care disparities as a quality and safety priority, has been elevated to improve health care equity as a new National Patient Safety Goal (NPSG.16.01.01). Additionally, TJC published 6 element performance requirements for ambulatory health care, behavioral health care and human services, critical access hospitals, and hospital accreditation programs at the start of 2023 in conjunction with the NPSG for improving health equity.¹ TJC standards develop an objective evaluation process to allow health care organizations to measure, assess, and improve performance.

TJC’s new requirements for reducing health care disparities follow below:

1. Designating individual(s) to lead activities to reduce health care disparities
2. Assessing the patient’s health-related social needs and providing information about community resources and support services
3. Identifying health care disparities in the patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients
4. Developing a written action plan that describes how the organization will address at least one of the health care disparities identified in its patient population
5. Acting when it does not achieve or sustain the goal(s) in its action plan to reduce health care disparities
6. At least annually informing key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce identified health care disparities

In addition to new requirements from TJC, CMS has published a 10-year framework (2022-2023) for health equity priorities to provide an integrated approach to health equity by outlining priorities for reducing disparities in underserved and vulnerable communities. Five of CMS’ health equity priorities are:

• Expanding data collection and reporting
• Assessing causes of disparities
• Building capacity of health care organizations to reduce disparities
• Advancing language access
• Increasing accessibility to health care services and coverage.

As part of this Framework, CMS adopted the Hospital Commitment to Health Equity measure in August 2023, which will be mandatory as part of the Hospital Inpatient Quality Reporting (IQR) Program’s requirements.¹² This measure in the IQR program will require hospitals to attest to whether they are prioritizing equitable care and assess a hospital’s commitment to establishing equity by capturing activities across strategic planning, data collection, data analysis, quality improvement, and leadership engagement.

IQR authorizes CMS to collect quality data from hospitals paid under the Inpatient Prospective Payment System to encourage hospitals and clinicians to improve quality and inpatient care costs. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandates IQR and allows CMS to pay hospitals that successfully report quality measures a higher annual update.¹³ With the finalized changes to the IQR program, hospitals are being rewarded with a 3.1% increase in their operating payment rates. These reimbursement rates continue to promote the use of SDOH data collection, especially after the change in severity designation CMS has placed for their SDOH codes describing homelessness.¹⁴ According to CMS Administrator Chiquita Brooks-LaSure, MPH, CMS wanted to recognize the higher costs that hospitals incur when treating those experiencing homelessness, as well as reward hospitals that are delivering high-quality care.¹⁵ More than 80% of hospitals were collecting SDOH data, but only around 50% were collecting it on a regular basis.¹⁶

References

1. TJC. R3 Report: requirement, rational, reference. Issue 38.2022. Accessed August 7, 2023. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_npsg-16.pdf

2. National Committee for Quality Assurance. Data, measurement, and equity. https://www.ncqa.org/health-equity/data-and-measurement/

3. Delandro T. Americans turning to ‘modern layaway’ to afford basics. News Nation. September 12, 2022. Accessed December 5, 2023. https://www.newsnationnow.com/business/your-money/americans-turning-to-modern-layaway-to-afford-basics/

4. Quality measures. CMS. Updated September 6, 2023. Accessed August 7, 2023. https://www.cms.gov/medicare/quality/measures

5. Population health management. AHA Center for Health Innovation. Accessed August 30, 2023. https://www.aha.org/center/population-health-management

6. Gopal DP, Chetty U, O'Donnell P, Gajria C, Blackadder-Weinstein J. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J. 2021;8(1):40-48. doi:10.7861/fhj.2020-0233

7. Heilman E. An intro to CMS’s SDOH measures. Medisolv blog. October 7, 2022. Accessed August 7, 2023. https://blog.medisolv.com/articles/intro-cms-sdoh-measures

8. Remington L. 2023 providers are responsible for social determinants of health quality measures. Remington Report & Think Tank Education. Accessed August 8, 2023. https://remingtonreport.com/intelligence-resources/home-health/2023-providers-are-responsible-for-social-determinants-of-health-quality-measures/

9. National Committee for Quality Assurance. HEDIS MY 2024 Volume 2. National Committee for Quality Assurance; 2024. https://store.ncqa.org/hedis-my-2024-volume-2-epub.html

10. Race & ethnicity stratification of HEDIS measures. United Language Group. Accessed August 8, 2023. https://www.unitedlanguagegroup.com/blog/race-ethnicity-stratification-of-hedis-measures

11. Hospital regulatory requirements to address health equity. Institute for Health Metrics. March 22, 2023. Accessed August 7, 2023. https://www.healthmetrics.org/blog-native/bridge-looks-pmm4l

12. Heilman E. A guide to CMS’s new health equity measure. Medisolv blog. September 2, 2022. Accessed August 29, 2023. https://blog.medisolv.com/articles/a-guide-to-cms-new-health-equity-measure

13. Hospital inpatient quality reporting program. CMS. Updated December 27, 2023. Accessed August 29, 2023. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/hospitalrhqdapu

14. Norris A. CMS ups reimbursement for certain SDOH codes. Healthleaders. August 7, 2023. Accessed August 16, 2023. https://www.healthleadersmedia.com/revenue-cycle/cms-ups-reimbursement-certain-sdoh-codes?utm_source=HLeNL&utm_medium=email&utm_campaign=HLRevCycle

15. New CMS rule promotes high-quality care and rewards hospitals that deliver high-quality care to underserved populations. News release. CMS. August 1, 2023. Accessed August 7, 2023. https://www.cms.gov/newsroom/press-releases/new-cms-rule-promotes-high-quality-care-and-rewards-hospitals-deliver-high-quality-care-underserved#:~:text=%E2%80%9CAs%20part%20of%20CMS%27%20health,CMS%20Administrator%20Chiquita%20Brooks%2DLaSure

16. Wicklund E. ONC: hospitals need to put SDOH data to use. Healthleaders. July 31, 2023. Accessed August 16, 2023. https://www.healthleadersmedia.com/technology/onc-hospitals-need-put-sdoh-data-use.