Government-industry collaboration helps drive toward equitable care
Evolving federal policy and the industry’s response puts more emphasis on providing cost-effective care, preventive services across diverse populations.
Researchers and policymakers have long been aware of discrepancies in health and quality-of-life tied to social determinants, because patients who are subject to poverty, racism, discrimination and other systemic issues perpetually demonstrate worse health outcomes.
Recently, the topic garnered increasing attention as the disparate impact of the COVID-19 pandemic brought health inequality to the mainstream. The conjunction of social media and social justice shone a bright light on the privilege of health.
In the U.S., as reimbursement models move from volume-based to value-based care, the economic health of provider groups and healthcare organizations increasingly is being tied to providing cost-effective quality care with an emphasis on prevention.
The Centers for Medicare & Medicaid Services (CMS) recently unveiled its strategic pillars, the first of which is Advance Equity. The intent of this pillar is to address health disparities that derive from systemic issues in the U.S. healthcare systems. Initiatives to provide greater equity include adoption of quality measures that promote equity and the expansion of benefits covered under the Affordable Care Act (ACA).
As part of this pillar, CMS also established a Framework for Health Equity, which is based around five key priorities:
The first of these priorities is garnering much attention in the EHR industry as government and independent bodies look to create standards and policies that support the standardization and interoperability of SDOH data.
The United States Core Data for Interoperability (USCDI) — a standardized set of data elements for nationwide interoperable health information exchange — incorporates new data elements that help identify social determinants of health. Version 1 includes basic demographic data that could affect health equity — such as race, ethnicity and preferred language — that can be used to identify populations subject to health inequity. Version 2 expands the demographic set to include sexual orientation and gender identity while also introducing data elements for SDOH goals, problems and health concerns, assessments, and interventions. Version 3 extends even further to include disability, and mental and cognitive status. Additional data elements under consideration in Levels 1 and 2 include health literacy, congregate living, refugee status, job pay grade and SDOH outcomes.
Information sharing regulations currently require healthcare organizations to honor all requests for this information for USCDI version 1; however, organizations should anticipate that higher versions will eventually be required and move to adopt as quickly as possible.
While Information Sharing requires exchange of data, it does not require any standardized format. This is where organizations like the Gravity Project factor in. The Gravity Project was initiated to identify and harmonize social risk factor data for interoperable electronic health information exchange. Currently, they are looking to codify data elements and associated value sets for SDOH across four clinical activities — screening, diagnosis, planning and interventions — with focus on three specific social risk domains — food insecurity, housing instability and quality, and transportation access.
As groups work to standardize the expression and sharing of SDOH data, CMS — through the Inpatient Prospective Payment System (IPPS) Final Rule — has included approaches that encourage providers to use SDOH data to identify socially at-risk populations and focus on improving their quality of care.
The IPPS includes two new measures that hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program will be required to report on — the “Screening for Social Drivers of Health” measure and the “Screen Positive Rate for Social Drivers of Health” measure.
The IPPS also includes a new “Hospital Commitment to Health Equity” measure that requires organizations to attest that they are reviewing and prioritizing equitable care in five domains — strategic planning, data collection, data analysis, quality improvement and leadership engagement. These measures are voluntary in 2023 and required by 2024.
Although CMS has provided the catalyst for change and organizations like the Gravity Project are establishing standards, it’s ultimately up to healthcare organizations to find the right workable solutions for their communities and cohorts and implement them. This means collecting the meaningful data needed to develop the right interventions and plans of care that will impact patients at the individual level.
Success also depends on understanding communities, how to effectively reach them and what programs can be established to overcome common barriers to care, most notably cost. Even with the latest EHR technologies, healthcare organizations cannot provide equitable care if patients forego treatment based upon cost.
Healthcare systems in the U.S. and globally are challenged with meeting the needs of patients whose life experiences undermine their ability to reach full-health potential, such as high deductibles or food and transportation insecurities. Uncontrolled chronic conditions drive care to higher acuity settings, escalating costs, and jeopardizing outcomes. If the ability to afford care rather than the affordability of care is a differentiator of outcomes, health inequity will persist.
To overcome SDOH barriers, organizations have to think outside of the box and outside of typical practice. Efforts must focus on building cooperation between healthcare organizations, community-based organizations and public policy-makers to introduce programs and initiatives that provide necessary support to populations with increased risk because of SDOH.
Health equity and outcomes improve when patients are supported in the ways they need. Getting to the root of those needs requires a strong patient-provider relationship built upon trust. Effective care management is the consistent thread that pulls the patient, care team and diverse care settings together to ensure everyone, especially the patient, has what they need to pursue the goal of optimal health. Health equity exists when the potential to reach full personal health is available to everyone.
Kate Jenkins-Brown is product manager of population health and care management of MEDITECH.