Social, economic, and geographic disadvantages create significant disparities in healthcare, such as lower quality of care and lesser health outcomes. To help improve these issues, the Centers for Medicare & Medicaid Services (CMS) redesigned the Global and Professional Direct Contracting Model under the new name, the Accountable Care Organization Realizing Equity, Access, and Community Health (or ACO REACH) Model. This new model will test ways to address health inequities by focusing on alternative payment structures that could better support accountable care delivery and care coordination.
What this means for the entire healthcare system isn’t yet fully known, but ACOs will find new policies to follow come January 2023. Chief among them will be to develop a health equity plan, which should detail identified health disparities and intended actions to remedy such inequities. ACOs must also apply health equity adjustments to performance benchmarks, capture demographic and social needs data, and implement beneficiary engagement incentives. When combined, the hope is to not only improve the delivery and coordination of care, but also encourage beneficiaries to change unhealthy habits and behaviors.
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Susan Richards Susan Richards is the director of risk adjustment programs and education at Episource. Susan is responsible for developing and managing the integrated programs that support end-to-end retrospective and prospective risk adjustment services, including provider education, HEDIS, and clinical documentation integrity. Nationally recognized as a leader in value-based care, Susan has more than 20 […]
Why the renewed interest in health inequities?
Health inequities began to be nationally recognized almost 20 years ago with the release of two Surgeon General reports documenting disparities in tobacco use and mental healthcare access by race and ethnicity. In recent years, the disparate impact of the pandemic on health outcomes and access to care based on socioeconomic factors has created renewed interest in health inequities.
To this end, CMS has put forth initiatives to address disparities involving racial and ethnic minorities, sexual and gender minorities, patients with disabilities, and beneficiaries living in rural areas. However, healthcare organizations are often left questioning where to start.
For one, the current ACO attribution methodology can make it difficult to connect patients to their primary care providers — or determine whether unengaged patients are even still part of their ACOs or Direct Contracting Entities. What’s more, CMS only provides participant lists annually. This can leave ACOs working off of outdated claim and claim line feed data, making it extremely difficult to coordinate care, let alone improve the quality of care delivery.
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Complicating matters further, many ACOs are comprised of independent practices contracted together with CMS, which can lead to a lack of unified infrastructure, interoperability opportunities, or centralized resources to aggregate and analyze data. This can leave those ACOs struggling to understand how to keep costs down, calculate risk adjustment factor scores, and identify members who need engagement efforts to improve health-related habits and behaviors (such as high-risk diabetics who could benefit from working with diabetes educators).
Finally, one of the key challenges in healthcare is engaging with an unengaged patient. If a healthcare organization can’t promptly ascertain a patient’s true clinical picture or effectively identify high-risk and low-risk populations, such errors can affect funding for needed care. Capturing social determinants of health (SDoH) can assist providers with properly addressing risks outside of clinical environments. Certain demographic groups have increased likelihoods of developing certain conditions based on socioeconomic characteristics.
The advantages of greater health equity
As ACOs begin to capture increasing amounts of data and develop deeper understandings of the communities they serve, opportunities for better patient engagement will naturally present themselves. Healthcare organizations should use all the information available to them to develop more impactful outreach programs — programs to improve health literacy and instill greater levels of trust in underserved communities. Trust has a direct impact on health outcomes, as people are more apt to seek care earlier when they trust their providers.
Solving inequities can also increase the healthcare system’s effectiveness in improving health outcomes. Risk adjustment, coupled with capturing SDoH factors, can be helpful in identifying high-risk, unengaged patients, as delays in care impact a disproportionate number of underserved community members and patients with chronic conditions. This, in turn, can result in more accurate health status assessments, projected healthcare needs, and predicted care costs. For example, take a Medicare Advantage patient with borderline Type 2 diabetes and hypertensive heart disease. If that person receives regular care, the danger of developing further diseases is reduced.
After all, almost any patient with a chronic condition who fails to receive regular care is at risk of experiencing a progression in their condition, leading to further complications. This scenario highlights the need to improve engagement efforts to ensure timely care delivery and optimize health management. It also allows healthcare organizations to determine health status, which can directly relate to identifying preventative care and quality interventions that can reduce overall utilization.
With an increasing number of healthcare organizations participating in merit-based incentive payment systems, it’s more important than ever to accurately determine the severity of an illness through proper diagnosis, documentation, and coding. Failing to code and apply the proper risk adjustment correctly could impact an ACO’s funding for care and overall quality of care performance, particularly those involving high-risk patients.
To effectively reduce disparities and improve the quality and coordination of care, government, providers, and healthcare organizations are beginning to collaborate on how to best address the factors driving gaps between populations. ACO REACH is another step in the right direction. As all parties start to implement the right procedures to abide by the new policies, we will begin to improve inequities in healthcare.
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Susan Richards is the director of risk adjustment programs and education at Episource. Susan is responsible for developing and managing the integrated programs that support end-to-end retrospective and prospective risk adjustment services, including provider education, HEDIS, and clinical documentation integrity. Nationally recognized as a leader in value-based care, Susan has more than 20 years of leadership experience in the healthcare industry.
