Health equity has always been the turning tide for the healthcare industry, but now regulatory leaders have pushed this effort to the top of the list. A subset of measures calculated in Star Ratings are the social risk factors for low-income, dually eligible, or disabled beneficiaries, of which Medicaid, Medicare Advantage, and D-SNP members reside.
Changes from CMS establish new benchmark Star Ratings for 2027. These new ratings will be calculated on data pulled from 2024 and 2025. Therefore, to succeed under this new schema, health plans must prioritize data collection this year to ensure better health equity outcomes and CMS compliance for at-risk populations in the future.
This blog series provides valuable advice for health plans to prioritize health equity index efforts in 2024, thereby laying the foundation for Star success and CMS compliance ahead.
Unpacking CMS’s Health Equity Index
CMS defines health equity as the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.
The Health Equity Index (HEI) reward in the 2024 CMS Final Rule impacts health plans’ 2027 Star Ratings and contract rewards. The initiative aims to drive equity in healthcare, combatting SDOH needs standing in the way of quality patient care.
While 2027 Star Ratings seem far out, these ratings will be measured from performance in 2024 and 2025. This ruling and its addition of the HEI reward do not just encourage health plans to drive clinical outcomes and interventions for members facing SDOH risks but will require them to perform just as well or better than those outcomes of other plans.
It is important to look at CMS’s priorities and understand how the proper use of SDOH data is vital to your plan’s sustainability. Here are two immediate priorities to consider. Part Two of this blog series will define priorities three, four and five.
Priority 1: Expand the collection, reporting, and analysis of standardized data
In 2021, CMS recognized the importance of Social Determinants of Health (SDOH) data and introduced the Community Health Access and Rural Transformation (CHART) Model, to close gaps in care for members facing expansive disparities, particularly in rural locations. Further increasing their priority of SDOH data collected by plans, they encouraged voluntary SDOH reporting in 2023. Followed by the now mandatory reporting due in May of 2024. From recognizing the importance of SDOH caps in care and encouraging then mandating its reporting, CMS has expanded this initiative.
Recognizing the vast disparities and unmet SDOH needs plaguing vulnerable populations, SDOH screenings encompass:
- economic stability
- neighborhood and physical environment
- education
- food
- community, safety
- and social context
- healthcare system accessibility and coverage
Understanding the direct correlation between disparate populations facing adversities in SDOH barriers to care, CMS prioritized the collection, reporting and analysis of this data.
Now mandatorily reported on, CMS wants plans to use collected data to pinpoint risk factors for each member, and take action to conduct proper health interventions. How to do so, requires more regulation and adherence leading to the next CMS’ next priority.
Priority 2: Access causes of disparities within CMS programs, and address inequities in policies and operations to close gaps
Running rampant in Medicare Advantage, Medicaid, and D-SNP plan members, CMS wants organizations to remove barriers to equitable care. The 2024 Final Rule sets new standards for health plans to uphold regarding how they remove these barriers hindering members’ healthcare and wellness.
Using the existing Star Rating measures, CMS will compare the outcomes of populations with social risk factors to those without. Meaning that outcomes driven in 2024 and 2025 will impact the benchmark Star Rating measurements in the frameworks goal year of 2027.
This encompasses CMS’s plan over the next decade, moving past identifying socially at-risk members to fully bridging the equity gaps in care.
CMS will initially evaluate contract performance against each health equity measure for low-income, dually eligible, and disabled plans and how they rank amongst each other.
- Highest performing plans in the top third rankings will receive 1 full point.
- Medium plans performing in the middle third ranking receive 0 points.
- Low performing plans in the bottom third ranking receive -1 point.
Each point will be multiplied by the weight of each measure, the sum of which will create the contract’s total weighted score. Then, dividing this score by the total measure weights, CMS presents the contract with its finalized HEI score. Which is held against measurable outcomes of regular plans. Those above 0 meeting the SRF membership enrollment threshold will be rewarded. However, those scoring below 0 are ineligible for rewards and face further setbacks.
The new CMS Final Ruling, changes to Star Ratings measurements, the introduction of HEI reward, and reporting SDOH data and proven outcomes is daunting to most health plans and their leaders. However, if using the right strategies, technologies, and partnerships, plans can not only sustain their standings but improve their Star Ratings and rewards.
86Borders stands ready to serve health plans as they prepare for CMS change. Three additional priorities will be covered in Part Two of this blog. Look for my next post in April to further explain the foundational steps health plans must take in 2024 for 2027 success.