Roma Sharma

The COVID-19 pandemic has brought social and racial inequity to the forefront of public health. In the United States, the pandemic has affected many communities, including racial and ethnic minorities as well as low-income populations, more severely than other groups.

Negative health outcomes are more common among individuals within these groups, and social determinants of health (SDOH) play a significant role. SDOH are the conditions where people are born, live, learn, work, play, worship and age; they are the wider set of forces and systems that affect a broad range of health, functioning, and quality-of-life outcomes and risks. Their importance has become increasingly apparent as research on health outcomes and risks has shown that the care delivered within the walls of a hospital or medical practice impact as little as 10% of an individual’s long-term health with SDOH affecting the remaining 90%. Now Centers for Medicare & Medicaid Services (CMS) and states across the country are playing a leading role in tackling health equity and SDOH.

Center for Medicare and Medication Innovation

 released a white paper titled “Innovation Center Strategy Refresh.” The Innovation Center (it was previously commonly known by its initials, CMMI) supports the development and testing of innovative health care payment and service delivery models, which often focus on value-based care. The white paper is intended to be a blueprint for the next 10 years and highlights five strategic objectives: drive accountable care, advance health equity, support innovation, address affordability, and partner to achieve system transformation. These objectives will further CMS’s vision: “A health system that achieves equitable outcomes through high-quality, affordable and person-centered care.”

The strategy outlined in the white paper aims to embed health equity in every aspect of the Innovation Center’s models and increase focus on underserved populations. To measure progress, all new models will require participants to collect and report the demographic data of their beneficiaries and, as appropriate, data on social needs and SDOH. The new models are also to include patients from historically underserved populations and safety net providers, such as community health centers, and to identify areas for reducing inequities at the population level, such as avoidable admissions and set targets for reducing those inequities.

In the white paper, CMS acknowledges that safety net providers often need dedicated and greater financial and technical assistance to provide equitable care, given they may need to make greater upfront investments if they are to succeed in value-based care arrangements. CMS is considering various incentives to encourage and sustain participation, such as upfront payments, social risk adjustment, benchmark considerations, and payment incentives for reducing disparities or screening for SDOH. There may also be funding for coordinating with community-based organizations that address social needs. These measures will provide new financial opportunities for community health centers, rural health clinics, community-based providers, and public and critical access hospitals, among other providers. The Biden Administration is taking other steps to address health equity, but the Innovation Center is likely to be a prominent part of the effort given the latitude it has to launch and test new payment and delivery models.

States also have a significant opportunity to lead in addressing SDOH because they are closer to their local communities. Some states are driving innovation through traditional levers and asking CMS to enhance Medicaid reimbursement flexibility, expand Medicaid eligibility criteria for certain populations, and approve transformation of SDOH infrastructure to serve Medicaid members.

Oregon’s latest 1115 waiver demonstration application draft released in December 2021 includes a goal to eliminate health inequities by 2030. Oregon hopes to achieve this by ensuring access to SDOH services to vulnerable residents experiencing certain life transitions, providing enhanced continuous eligibility for certain populations, and to use federal savings from a state cost growth target program to invest in community-led infrastructure that will drive equity.

Similarly, New York’s 1115 waiver demonstration concept papers, released in 2021, propose two new collaborative organizations to drive equity infrastructure and interventions: Social Determinants of Health Networks (SDHNs) and Health Equity Regional Organizations (HEROs). SDHNs would formally organize community-based organizations, providers and payers into a coordinated system to drive regional referral networks and organize interventions. HEROs are “mission-based organizations” which would drive the planning and assessment needs of regions to best inform equity investments and interventions.

To build long-term social and physical health structures that are inclusive, effective and sustainable, a majority of states have built coordinating organizations to direct the state’s strategic response to health inequities exacerbated by the COVID-19 pandemic. These coordinating organizations are typically representative of populations impacted by disparity, are time-limited in duration and often tied to the state’s COVID-19 public health emergency declaration. A number of recommendations from these bodies have been incorporated into law. They run the gamut, from requiring implicit bias training for certain providers as part of their continuing education requirements, to state investment in integrating low-cost, sustainable wrap-around community support for Medicaid members that are typically not currently covered (i.e., limited legal services, tenancy support services, risk assessments, job placement assistance, and education services). Other changes include removing scope of practice or supervision barriers to enhance the ability of advanced practice providers to practice more independently to enhance representation of the provider workforce in vulnerable communities, and investment in infrastructure to build interoperable systems for equity data collection.

States are also taking steps to build equity-related requirements into their Medicaid contracts with managed care organizations (MCOs). In recent years, many states have taken consistent steps to build an understanding of inequities in member populations, such as requiring Medicaid MCOs to collect and stratify member and provider data, such as quality measures, by language, race, and ethnicity. However, states are more frequently pivoting to a proactive stance. For instance, in recent Medicaid MCO requests for proposals (RFPs), three states – Indiana, Louisiana and Nevada – joined a limited number of other states who require MCOs to submit annual health equity plans, which illustrate how MCOs are effectively addressing disparities in care that exist in their member population. Other states have required MCOs to hire specific staff dedicated to health equity program development or implicit bias training for member-facing staff.

In 2022 and beyond, CMS and states will likely continue to grapple with two pressing needs. First, as described in the CMS Innovation Center’s white paper and as made evident from these coordinating organizations, continued focus should be given to the lack of integration between health data, social care data, and consistent standards for SDOH data collection. CMS has emphasized the need for increased focus in this area; states should continue to utilize these coordinating organizations to collaborate with providers, payers, and CBOs on a policy framework for implementing a feasible vision for health equity data collection and application. Federal guidelines on the collection of appropriate demographic, health equity, and SDOH data and the purpose and use of such data may help to standardize the collection across states and entities.

Second, states need to consider how they plan to sustain the work of the established coordinating organizations beyond the COVID-19 pandemic. While many of these organizations had a timeline tied to the state’s public health emergency declaration, adequately investing in an infrastructure extending beyond the pandemic will be a requisite to ensure care delivery and social systems sustain transformation in a non-pandemic environment.

Furthermore, private entities such as MCOs and hospital systems can take actions to advance health equity as well by negotiating terms and conditions into contracts that require all parties of the contract to monitor and report to one another health equity efforts, such as community investment, bias training, and diversity of staff.

While such efforts at the federal, state, and private levels are underway, it will be critical to not only collect and analyze data to understand health inequities but to then incentivize or require parties to create solutions that eliminate those inequities over time. While CMS and states across the country will continue to play leading roles in tackling health equity in 2022 and beyond, it is clear that solutions in this space will not come from a single actor, but more broadly from the combined efforts of the entire healthcare infrastructure working together.

is counsel in Crowell & Moring LLP’s Health Care group.

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CMS and state officials are using payment incentives, data collection and program requirements to start edging the lofty ideals of health equity toward reality.