CMS Incentivizes Payor Health Disparity Performance
Medicare Advantage and other health plans are starting to pay more attention to medication adherence, social determinants or drivers of health (SDOH), and where they can intervene in health disparities—not only because it’s the right thing to do but because it will soon affect their bottom line, speakers said at Asembia’s AXS24 Summit, in Las Vegas.
“There is now evidence that if you don’t address social drivers of health, you are not going to achieve good outcomes for a big percentage of the population,” said Christie Teigland, PhD, the vice president of research science and advanced analytics at Inovalon, a software and data solutions company.
SDOH drive about 80% of health outcomes, Dr. Teigland added. “Only about 20% of our health outcomes is due to the actual clinical care we get. The rest is related to things like income, education, the environment in which we live and our health behaviors. We need to understand them and how they might drive access to care and medication adherence.”
Medication adherence measures that are part of value-based payment systems are now being incorporated in the Centers for Medicare & Medicaid Services’ new Health Equity Index (HEI). The HEI was developed as an enhancement to Medicare Advantage plans, with a goal to incentivize contracts to perform well for beneficiaries with social risk factors, she said. For now, the population being studied includes members who are dually eligible for Medicare and Medicaid, those who receive a low-income subsidy, and those with disabilities, “not because those will be the only SDOH that are important, but because that’s what they have good access to data on,” Dr. Teigland said.
The HEI will consider Star Ratings of performance for 2024 and 2025 on 12 quality measures such as:
- adherence for cholesterol, hypertension and diabetes medications;
- statin use in people with diabetes; and
- rheumatoid arthritis management.
The goal of the HEI initiative is to look for disparities in outcomes among people with SDOH and where health plans can intervene, Dr. Teigland noted.
“Those big disparity gaps are really where plans are going to have to focus their efforts to do well on this Health Equity Index, because they’re going to get ranked against everyone else and get scored,” she said.
Performance on these measures will factor into a financial reward or bonus payment for plans starting in 2027. “The trick about these medication adherence measures [for diabetes, cholesterol and hypertension medications] is that they are triple-weighted in this index,” she explained. Plans that rank in the top will get 3 points, those that rank in the middle will receive no points and those in the bottom will get 3 points taken away from their score, “so these are going to be really impactful to plans.”
Although the HEI is initially starting with only a couple of social drivers, it behooves health plans to start tracking the effect of additional factors such as race/ethnicity, education level, household income, social isolation/living alone and English language proficiency, Dr. Teigland said. These entities also should be looking at their performance on medication adherence and other measures among members who are dually eligible, disabled or receive the low-income subsidy versus those who do not, using analytics and medical and pharmacy claims.
“It’s important that they do that exercise to understand where their biggest disparity gaps are,” she said. By doing so, “they can focus their limited resources to improve where it’s going to make the biggest difference in their HEI score.”
Filed under: General Problems
Leave a Reply