Health Equity Measures Determine The Impact Of New CMS Regulations And Funding

New federal initiatives and CMS funding support quality improvement by prioritizing health equity measures

New healthcare quality improvement priorities gain traction when the federal government creates regulations and CMS backs those regulations with funding. Health equity (HE) received such a boost in 2021 and 2022 with executive order 13985, the final rule that designates “Birthing-Friendly" hospitals for maternity care and proposed policies for Rural Emergency Hospitals (REH). Health equity measures will be key to tracking outcomes from new programs and funding.

This two-part article sheds light on recent government initiatives and places quality measures into historical context. In article two, we'll discuss two types of measures and how quality is being addressed through health equity measures.

Recent regulations and proposals aim to improve maternal health and rural health equity

In January 2021, President Biden issued Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, along with other organizations focused on equity. This was the first time in recent history that the Centers for Medicare & Medicaid Services (CMS), along with all other federal agencies, were charged to undertake a whole-of-government approach to enhance and extend identifying, understanding, and addressing barriers to equitable health.

The CMS plan strives to improve health equity in three critical ways:

• Designing, implementing, and operationalizing policies and programs that support the health of all the people CMS serves
• Eliminating avoidable differences in health outcomes experienced by people who are disadvantaged or underserved
• Providing the care and support that our enrollees need to thrive

The CMS Framework for Health Equity 2022-2023 outlines an integrated, action-oriented approach to advance health equity, as well as guidance for providers, health plans, and other organizations that serve their communities. The framework updates the 2015 Medicare-focused CMS Equity Plan for Improving Quality in Medicare, providing a more comprehensive 10-year plan to deliver greater equity across all CMS programs -- Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Marketplace.

Demonstrating improved health equity for mothers through birthing-friendly hospital designation

One such program that is part of the final rule is the “Birthing-friendly" hospital designation. This designation identifies hospitals that “demonstrate a commitment to improving maternity care quality through their participation in quality improvement collaboratives and implementation of best practices that advance healthcare quality, safety, and equity for pregnant and postpartum parents."

The rule contains three health equity measures in hospital quality programs and awards hospitals that “participate in a statewide or national perinatal quality improvement collaborative program and have implemented the recommended quality interventions. Consumers will be able to access performance measures and information about hospitals with a demonstrated commitment to reducing maternal morbidity and mortality by implementing best practices that advance healthcare quality and safety for pregnant and postpartum patients." These efforts are part of the CMS Maternity Care Action Plan.

Increased payments for meeting three health equity measures

As part final rule for FY 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS), CMS is adopting three health equity-focused measures as part of the CMS quality data collection program called Hospital Inpatient Quality Reporting (IQR):

• One health equity measure assesses a hospital's commitment to establishing a culture of equity and delivering more equitable healthcare by capturing concrete activities across five key domains -- strategic planning, data collection, data analysis, quality improvement, and leadership engagement
• Two health equity measures around screening and identification of patient-level, health-related social needs — food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety

Supporting improved health equity for REH and behavioral health in rural communities

In July 2022, CMS proposed actions to advance health equity and improve access to care in rural communities by establishing policies for Rural Emergency Hospitals (REH) and providing payment for specific behavioral health services furnished via communications technology. The proposal would expand access and permanently allow behavioral health services delivered in the home via telehealth.

Why is CMS driving health equity measures?

CMS is the United States' largest health insurer. Additionally, they are responsible for ensuring that Americans receive quality, effective, and efficient healthcare. But, how did CMS become the champion for driving improvements in health equity? It stems from a history marked by evolving from an entity established by law as the financial backer of healthcare to also becoming a major influencer on clinical care and healthcare quality through data collection, analysis, and quality improvement programs. When Medicare was established, CMS quickly realized that greater financial oversight was needed, as well as a way to ensure services that the government (and its taxpayers) were paying for were worth the price. Then, in 1993, quality improvement became a tool by which Federal policy could measure and track healthcare quality. In 2003, quality improvement organizations (QIOs) took over the work of developing prospective quality improvement initiatives and providing additional oversight.

CMS has evolved from a financial body to overseeing healthcare quality, including health equity

Today, CMS has a host of quality improvement programs and measures carried out in collaboration with another Federal agency called the Agency for Healthcare Research and Quality (AHRQ). As highlighted in their 2021 triennial National Impact Assessment of CMS Quality Measures Report, CMS tracks and reports on the analysis of quality measures across 26 CMS quality programs. The recent report highlights substantial improvements in care quality, cost efficiency, and burden reduction, reflecting positive feedback on how measures have impacted organizations and patients.

Since CMS was established 50 years ago, along with the creation of Medicare and Medicaid, clinical medicine and the quality of healthcare in the US have been under the purview of CMS. What began as a regulatory model is now a significant force for quality improvement in medicine.

How does CMS support minority health and health equity?

As shared earlier, CMS provides the financial backing for QI and HE programs that affect people within programs like Medicare, Medicaid, CHIP, and the Marketplace. The CMS framework comes out of the CMS Office of Minority Health, which serves as the principal advisor to CMS on the needs of historically marginalized populations. These populations would include racial and ethnic minorities; people with disabilities; members of the LGBTQ+; individuals with limited English proficiency; and rural populations. It also advises on health inequities, providing recommendations to address barriers to achieving more equitable healthcare.

What's next for health equity measures and initiatives?

CMS is currently planning several programs incorporating health equity measures:

• Expanding collection, reporting, and stratification of data across all CMS programs
• Creating new health equity-focused measures
• Working towards building health equity reporting metrics into quality improvement (QI) programs
• Increasing the availability of and access to CMS data for researchers and external partners
• Rolling back restrictive policies that inhibit access to coverage and care in Medicaid
• Implementing 12-month postpartum coverage in Medicaid
• Increasing enrollment efforts in Marketplace plans among underrepresented communities
• Considering ways to encourage greater participation for safety net providers in accountable care organizations and value-based care

And in the August 2022 announcement of the prospective payment rule, CMS shared an interest in “using measures focused on connecting patients with identified social needs to community resources or services." Together, these recent developments will provide funding that creates momentum for healthcare organizations to initiate health equity programs and to use their QI capabilities to measure, track, and report on HE progress.

Health equity measurement: viewing quality through two types of measures

There are two types of quality measures. Those that are regulatory-driven -- required or incentivized by the Federal government – and measures recommended from QI organizations and programs, including Federal departments and other non-profits, think tanks and research organizations.

In article two of this series, we'll discuss specific health equity measures: how various organizations created those frameworks and provided the evidence for their best practices.

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