Health equity is the attainment of the highest quality of healthcare for all people regardless of sociodemographic characteristics and social determinants of health. Forging the path towards health equity will require coordinated efforts from all healthcare stakeholders including payers, providers, and community-based organizations.
Several influential healthcare organizations such as CMS and NCQA are including health equity in formal requirements and accreditations. Additionally, organizations such as NQF, IHI, and RWJF have published frameworks to guide healthcare organizations in addressing health disparities. As we work to create a more equitable healthcare system, these requirements and frameworks highlight key areas where organizations should focus their attention to improve treatment and outcomes for underserved populations.
In this interview, learn about the motivations for health equity work and the main requirements and strategies found in health equity accreditations and frameworks.
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Definitions of health equity
As we talk more about health equity, definitions are important. For many of the organizations that I'll be talking about today, definitions guide their understanding of health equity and the communities that they serve. Different definitions highlight different aspects of equity. Some organizations define health equity as the elimination of disparities, while others define it as more of an outcome that's achieved when everyone has an equal opportunity to improve their health. I personally liked the Robert Woods Johnson Foundation definition that highlights health equity as both a process and an outcome.
After reading several definitions of health equity, I wanted to narrow down the definition to a more concise form that encompassed all the definitions that I was reading. What I came up with is that health equity is the attainment of the highest quality of healthcare for all people, regardless of sociodemographic characteristics and social determinants of health. This is how I've been thinking about health equity over the past month to help inform my research on the topic.
Key factors to health equity
Other definitions that are important when discussing health equity, our social risk, social need, and social determinants of health. NCQA defines social risk as specific adverse social conditions that are associated with poor health outcomes. Examples of social risk would include social isolation, housing instability and poverty. NCQA also defines social needs as the non-clinical needs that individuals identify as essential to their wellbeing. The key takeaway is that social risk informs social needs. People can have the same social risk but have different social needs. And lastly, the CDC defines social determinants of health as conditions in places where people live, learn, work, and play that affect a wide range of health and quality of life, risk, and outcomes.
Motivating factors to pursue health equity
So why is health equity such a hot topic right now? There are a few recent developments that have brought this topic to the attention of the healthcare industry. One of the first driving factors were the social justice movements around racial justice during the summer of 2020. Large scale protests put a spotlight on inequities that exist for racial and ethnic minorities in America. Simultaneously, we saw that COVID-19 was disproportionately affecting minority communities. Both circumstances put a lot of pressure on healthcare officials to recognize racism as a public health crisis and actively participate in increasing health equity.
The second driving factor is the priorities of the Biden-Harris administration regarding health equity. In response to racial justice movements, the administration is taking actions to increase health insurance coverage for people of color, combating maternal health disparities and expanding Medicaid coverage. Lastly, research from major health organizations, such as the CDC, WHO, and NIH has highlighted the impacts of social determinants of health. According to the WHO about 30% to 55% of health outcomes can be explained by social determinants of health. All these factors combined have encouraged major healthcare organizations to create actionable goals around health equity and encourage providers, payers, and health systems to do the same.
Health equity initiatives overview
To give an overview of the different health equity initiatives I'll be talking about, the first category consists of official health equity requirements and accreditations. NCQA and CMS are the only two organizations of those that I investigated that currently have official accreditations in place. Next, I'll talk about health equity frameworks that have been published by CMS, NQF, IHI, and the Robert Wood Johnson Foundation. By contrast, these documents are more general recommendations on how to advance health equity without an official accreditation tied to them.
These documents serve as resources for payer and provider organizations to consult when thinking about how to increase health equity. Lastly, I'll talk about different health equity resources from the Joint Commission and the FDA. These organizations have not published official accreditations or frameworks, but they have different resources on their websites about health equity. While they haven't published anything official right now, they may release something in the future.
NCQA accreditation distinctions
So, starting with NCQA, NCQA has served as a leader in encouraging culturally competent healthcare services over the years. They originally created the distinction in multicultural healthcare to recognize health plans and other care organizations that were excelling in culturally and linguistically sensitive services and reducing health disparities. Key requirement areas included in this distinction were collecting race, ethnicity, and language data, providing language assistance, cultural responsiveness, quality improvement of cultural and linguistically appropriate services, and the reduction of healthcare disparities.
This distinction was marketed to identify gaps in care, lower cost, stand out in the market and establish standardization for multicultural healthcare. The distinction of multicultural healthcare has now become the health equity accreditation. The health equity accreditation has the same five goals of the previous distinction, with the addition of the organizational readiness goal. This accreditation provides more robust standards around health equity and is meant for organizations who are in the beginning stages of their journey to establishing health equity norms. Health plans that have the distinction in multicultural healthcare can opt to extend that distinction or renew into the health equity accreditation, depending on when their distinction expires. Surveying for the health equity accreditation started on July 1st, 2022.
Health accreditation plus option
While the health equity accreditation is for organizations in the beginning of their health equity journey, health equity accreditation plus is for more advanced healthcare organizations who already have the health equity accreditation and want to pursue more advanced goals. This accreditation has more requirements focused on combating social determinants of health and establishing community partnerships. There are 5 main categories of requirements that organizations should focus on to achieve this accreditation. The first requirement is for organizations to provide a program to improve social risk and address social needs. This entails organizations documenting their detailed process with measurable goals of how they will identify and address social risk and needs. Additionally, they'll need to evaluate the effectiveness of their process every 3 years using performance measures. This data will need to be analyzed to help identify future areas for improvement.
New data collection requirements
The next and most substantial requirement is the collection integration and analysis of community and individual data. Satisfying this requirement involves performing stratified data analysis to identify and address social risk and social needs at the community and the individual level. NCQA is requiring organizations to utilize at least 3 data sources for community level social risk data, one of which should be a community assessment performed by a local public health agency. Health plans are also encouraged to use population segmentation to understand where certain populations have intersections in their social risk and needs. The process of analyzing community and individual level data must be done annually to inform what areas should be prioritized in the work plan that I mentioned before.
Operational foundation for health equity accreditation plus
The community sector partnerships and engagement requirement are another unique requirement to the health equity accreditation plus. Much of this requirement relies on the organization setting up plans to identify appropriate community partners. They need to have a process in place to identify those partners, plans for data sharing with those partners, a process to work with them to provide resources to the community, a comprehensive resource directory, and a process for supporting community interventions. They also must have an advisory board in place that surveys members of the community and individual consumers on how well these partnerships are meeting social needs.
Data security measures protect privacy
The data management and interoperability requirement are all about creating robust security protocols to protect sensitive data. Organizations must have protocols in place to protect social needs data with specifications about data sharing, appropriate use of data, physical and electronic access to data, and individual's data-sharing preferences. They're also required to communicate with individuals about their data privacy policies at least once a year. And the last requirement centers around referrals, outcomes, and impact. This requirement involves working closely with individuals to ensure that the referral process is appropriate, timely, and effective. Health organizations are responsible for tracking the status of referrals, analyzing if disparities exist in the referral process and working with partner organizations to assess the effectiveness of the referral process. All these requirements are described in more detail in the NCQA Health Equity Accreditation Plus Appendix of Standards.
REACH accreditation overview
Another accreditation that's getting a lot of attention is the ACO Realizing Equity Access and Community Health (REACH) model. This program will go into effect at the beginning of 2023. The purpose of this model is to build on CMS's previous global and professional direct contracting model with a focus on reaching vulnerable populations who utilize Medicare. The new REACH model aims to extend the benefits of ACOs to underserved communities, empower provider-led organizations and protect beneficiaries by using a more rigorous participant monitoring process. Standard ACOs, new entrant ACOs, and high-needs-populations ACOs are eligible to apply for and participate in the REACH model.
The model offers 2 voluntary risk-sharing options. The first is the professional option, which is a low-risk option that only involves 50% shared savings and losses associated with primary care. The global option is high risk and involves 100% shared savings and losses associated with primary care and total care. The REACH model is no longer accepting applications, but it will go into effect on January 1, 2023, for those who were selected to participate.
CMS health equity priorities
In addition to the ACO REACH model, CMS released a general framework for incorporating health equity across different CMS programs. Like NCQA, one of CMS's top priorities is to expand the collection reporting and analysis of standardized data. The agency is working on collecting more data on social risk factors, experience of care, and patient demographic data such as, race, ethnicity, language, gender identity, sex, sexual orientation, and disability status. The goal is to use this data to identify the needs of underrepresented populations and work more accurately with community partners who are already serving those populations.
Community partnerships key for CMS approach
Another key objective is to address where disparities exist within CMS due to equitable organization policies. CMS is working to make coverage across all programs more affordable and available. This will involve evaluating the impact that social risk factors have on value-based payment models. Increasing healthcare coverage has been a CMS priority for many years now. Again, emphasizing the importance of community partnerships, CMS wants to help build the capacity of healthcare organizations to reduce health disparities. And they'll do this by encouraging providers who have not previously participated in value-based care to try implementing those payment models.
In support of that effort, CMS is making sure that the eligibility criteria and application process is accessible to providers that treat a variety of patient populations, especially those communities that are rural and, or underserved. CMS would also like to advance language access, health literacy, and culturally tailored services. They'll accomplish this by implementing more touch points for patients such as patient navigators to help patients understand the health insurance enrollment process based on their unique financial situation.
Expanding care accessibility
Additionally, CMS wants to increase the availability of preferred language data. This will help patients get care in the language that they understand and increase informed decision making between providers and patients. Lastly, CMS is focused on increasing accessibility. This priority is centered around making care accessible for those with disabilities. This will mean improvements to infrastructure, provider education, and providing more patient and family centered care. To make this happen, there must also be data collection from healthcare professionals on accessibility.
NQF health equity implementation step 1
By contrast to other health equity frameworks, NQF's framework is more specifically focused on quality metrics. NQF identifies 4 objectives for implementing health equity and quality measurement. The first step is to identify and prioritize reducing health disparities. To identify health disparities, NQF encourages organizations to use disparity sensitive metrics that view quality across different institutions and social groups. Disparities can be viewed in terms of prevalence, size, impact, and feasibility.
NQF health equity implementation step 2
The next step is to implement evidence-based interventions to reduce disparities. This will require payer and provider organizations to consult best practices for improving health equity. Some suggestions that NQF provides are culturally informed treatment, community educational programs, partnerships with community health workers, and diversity equity and inclusion training for staff.
NQF health equity implementation step 3
In addition to quality metrics and evidence-based solutions, organizations must also invest in the development and use of health equity performance measures by building an internal foundation for health equity. To accomplish this, they recommend implementing an organizational culture of equity, creating structures that support that culture of equity, ensuring equitable access to healthcare, ensuring high quality healthcare, and partnering with community organizations that influence social determinants of health.
NQF health equity implementation step 4
Lastly, NQF states the importance of incentivizing the reduction of health disparities and achievement of health equity. They list 10 specific actions that will help reduce health disparities. One unique recommendation of theirs was to invest in preventive primary care for patients with social risk factors. I also thought it was interesting that they directly called for health equity measures to be tied to accreditation programs. To me, the signal that these disparity sensitive metrics may play a more critical role in the future when it comes to health equity accreditations
Institute for Healthcare Improvements
The Institute for Healthcare Improvement’s health equity framework serves to, 'provide practical advice, executable steps, and a conceptual framework that can guide any healthcare organization in charting its own journey to improved health equity.' The first step in doing this is making health equity a strategic priority.
IHI procedural recommendations
IHI recommends that organizations build health equity into their business and organization plans. This can include incorporating health equity into executive compensation plans and leaning on community business models that involve community partnerships to decrease social determinants of health. They also recommend implementing payment models, like those used by ACOs, that prioritize outcomes. They also state the importance of developing structures and processes to support equity work. Specifically, organizations need leadership and funds in place to support health equity. This may come in the form of an oversight committee to lead everyone in the organization to focus on health equity goals.
Strategies for improving health services
The most substantial part of the IHI framework is the development of specific strategies to address multiple determinants of health.
They list specific strategies across the areas of health services, socioeconomic status, physical environment, and health behaviors. Recommended strategies for improvement in health services include collecting and analyzing race, ethnicity, and language data, quality improvement efforts for marginalized groups, community health needs assessments, and expanding primary care. Regarding socioeconomic status, healthcare organizations should provide economic and development opportunities for their staff, use diverse vendors whenever possible, and build healthcare facilities in underserved communities. Relatedly, hospitals can improve the physical environment by reducing pollution and waste and investing in public wellness spaces such as parks and walking trails.
IHI strategies for communities of color
Lastly, hospitals can encourage positive health behaviors through community education and wellness campaigns. IHI also calls on organizations to decrease institutional racism. Some ways that they suggest healthcare organizations do this is by creating physically welcoming spaces in communities of color, accepting more Medicaid patients, and reducing provider biases in the care-delivery process. Lastly, like other organizations, IHI is encouraging organizations to work with community partners and safety net providers who are already working with underserved communities and understand their needs.
Health equity is more than 'do no harm'
The last health equity framework that I'd like to quickly summarize is the framework from the Robert Wood Johnson Foundation. First and foremost, they attest the importance of committing to their mission. And their mission is to improve the health and wellbeing of all individuals, regardless of social determinants of health and demographic characteristics. This mission can often get lost in the bureaucracy of healthcare. They state how healthcare stakeholders need to do more than just 'do no harm.' They need to provide the best care by partnering with other professionals who do more work to address social needs.
Confronting inequalities within healthcare
Secondly, they believe in the pursuit of health equity, racial justice, and the elimination of all forms of discrimination. This principle focuses on confronting inequalities within society, the local community, and the healthcare system at large. It functions as a call-out to address systemic racism, discrimination, and inequalities by creating explicitly anti-racist policies.
Organizational responsibility to the community
Next, they address healthcare organizations' responsibilities to the community. Healthcare organizations are in a good position to partner with community organizations. Hospitals treat illness that is created by social inequities that exist in the broader society, so by working with other public health organizations, they can jointly address health equity. The next aspect of this framework addresses power. Power refers to the responsibility of the healthcare industry to be a leader in health equity because healthcare organizations are often 'anchor institutions.' This means that they employ many members of the community and have the reach and economic resources to help a lot of people.
Healthcare organizations are encouraged to be mindful of power imbalances that exist between healthcare professionals and community members. Checking this power is critical for ensuring equitable care. The last principle of the framework attests the importance of trusting relationships. This principle focuses on building trust with community members and respecting their needs and priorities, which involves getting to the root of where and why cultural mistrust may exist.
Joint commission health equity initiative
I also wanted to highlight 2 more organizations that are doing health equity work. The first is the Joint Commission, a big accrediting body for hospitals providing high quality care. The Joint Commission published a website on health equity that details their commitment to reducing health disparities. They recently announced that they will be adding more specific requirements around health equity in summer 2023. Called the Health Care Equity (HCE) Certification program, it will "recognize hospitals and critical access hospitals that strive for excellence in their efforts to provide equitable care, treatment, and services."
FDA health equity initiative for clinical trials
The FDA's Office of Minority Health and Health Equity has created the enhanced equity initiative to provide a large supply of online educational resources around health equity. The website contains several resources about health equity organized by different health conditions, such as asthma, HIV, and kidney disease. Another one of the FDA's key focus areas is to increase the availability of clinical trials data on racial and ethnic minorities. Lastly, they are supporting health equity research and partnering with diverse professionals to answer important questions about health disparities.
Trending topics in health equity
In conclusion, as health equity becomes a focus area in the healthcare industry, there will be more opportunities for healthcare organizations to implement effective strategies. Across all the accreditations and frameworks that I've mentioned, there are main themes and requirements that we see mentioned all these organizations have some objective related to equity focused data collection and analysis. They all also mentioned community partnerships and equity and organizational policies. Another trend that I noticed was that the IHI and Robert Wood Johnson Foundation frameworks are the only ones that explicitly call on organizations to address systemic racism. Pinpointing the nuances between these frameworks is important to make sure the right one is utilized for the right priorities.
Key considerations for future implementation
Ideally healthcare organizations can lean on all these frameworks to inspire targeted health equity work. Looking toward the future, healthcare organizations now need to work backwards from these goals by developing implementation strategies to achieve health equity. This could mean undergoing an equity-focused program evaluation, collecting more race, ethnicity, and language data, developing health equity plans, or using more disparity sensitive quality metrics.
Evidence-based solutions are key to success
Throughout all the next steps, it will be important to elevate evidence-based solutions for promoting health equity. We want to make sure that we're leaning on strategies that have been shown to work. And over the next few years, this type of evidence will become more readily available as more organizations do more health equity work.