Dora Hughes, M.D., M.P.H., chief medical officer at the CMS Innovation Center at the Centers for Medicare & Medicaid Services, said the Innovation Center’s 10-year anniversary was a good time to look both back and forward at how its models impact health equity and how the organization can do a better job of measuring the models’ impact.
Speaking on a March 23 panel at a summit put on by the University of Michigan’s Center for Value-Based Insurance Design, Hughes said that at the 10-year anniversary of the CMS Innovation Center, it made sense to take a step back and think about what it has accomplished and what they had learned from the past 10 years, and where do we want to go to achieve a health system with equitable outcomes.
In advancing health equity, Hughes described four main areas of focus. “The first is as we are creating new models or modifying models, how are we embedding health equity? What are the care delivery interventions? How are we recruiting? What are some of the payment considerations?”
The second area of focus is the recruitment of safety net providers, including Federally Qualified Health Centers, rural health clinics, and behavioral health clinics. “We're focused on that, in part, because we need to increase the number of beneficiaries from underserved populations who are participating in our models,” she said. “When we took a step back, we realized that because of a variety of factors, we didn't have that many safety net providers, and given that they care for underserved populations, the key to getting to more diverse beneficiaries is by increasing the number of safety net providers in our models.”
The third area is an enhanced focus on evaluation. “At the end of the 10 years, when we took a look back, we realized that because we weren't specifically asking ourselves what is the impact of our models on health equity, we don't know actually what impact they've had on access and quality of care for underserved populations,” she explained. “So the CMS Innovation Center is trying to be very deliberate from the very earliest stages of conceptualizing models in terms of understanding the questions they have to ask to get to a robust evaluation.”
The final area is focusing on strengthening the collection of demographic data as well as data on social determinants of health. CMS recognizes that greater data availability is key to monitoring and evaluating its models and to inform design.
In addition to an internal team focused on health equity, the CMS Innovation Center is increasingly working in a coordinated fashion with colleagues in the Medicaid Center, the Medicare Center, and in the Center for Clinical Standards and Quality. Hughes said the CMS Office of Minority Health is helping to coordinate these efforts as well.
She mentioned that the recently announced ACO Reach model has several equity provisions. One is requiring demographic data collection for those that participate in that model. The second is that model participants are required to prepare health equity plans to describe how they intend to address disparities. Third, participants that are serving a disproportionate number of underserved beneficiaries will receive a payment adjustment, recognizing that in many cases, caring for these potentially more medically and socially complex patients will require a higher level of resources.
“Also, when we're looking at the applications, we want to know, what has your experience been? What's your track record caring for underserved populations? And we will be seeking to add that to as part of our review, along with all the other factors that are certainly very important as well,” Hughes said. “We want to get safety net providers and others who might be newer to the ACO space to join us as we work to promote equity.”
Hughes said that although CMS has tremendous amounts of data internally, much of it is not the best quality. “We are also reaching outside of CMS to some of our agency partners to see what data they may have — for example, in the Department of Housing & Urban Development, what data do they have on housing insecurity, and could we match that with some of our programs?”
On a parallel track, they are thinking about what they can do for the new models that they will be rolling out in the next few years. “What are some of the requirements that we might put in place for participants to collect data, to ask their patients so that we can have more patient-reported data, which is, in many cases, considered the gold standard,” she said.
