Are You Prepared for CMS's New Health Equity Measure?

Understand the 5 domains of CMS’s new health equity measure and gain unique insights into each from our experts.

November 15, 2022
CMS Health Equity Measure

In August of this year, Centers for Medicare & Medicaid Services (CMS) released the final rule for the federal fiscal year (FY) 2023 inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) payment system. This final rule included many changes such as reimbursement increases for Medicare, improvements for mental health and COVID-19-related changes.

However, the item that caught our eye was the “Hospital Commitment to Health Equity” measure. This will be mandatory as part of 2023 Inpatient Quality Reporting (IQR), and hospitals must participate in the IQR program to receive full IPPS rates. The intent of this measure is for hospitals to make health equity a strategic priority. Given the gaps in access, quality and outcomes for vulnerable populations, CMS is encouraging all healthcare leaders to advance health equity.  

This measure comprises of 5 domains. To receive a full point for each domain, all elements within each domain must be satisfied.

Domain 1: Equity is a strategic priority

The hospital needs to have a strategic plan for advancing health equity that:

• Identifies priority populations with health disparities

• Establishes healthcare equity goals and action steps to achieve them

• Outlines specific resources which have been dedicated to achieving these goals

• Describes approach to engaging key stakeholders such as community partners

Our take: In addition to hospitals completing their Community Health Needs Assessment (CHNA) every 3 years, it needs to align quantitative health equity goals with action steps necessary to execute. Additionally, hospitals need to find resources and/or technology that help in achieving these goals efficiently. For example, cost-related medication nonadherence is a big factor in hospital readmissions: patients skip medication doses, take less or delay filling a prescription because they can’t afford it. Having a patient assistance program with robust technology can fill this gap because whole or partial medication costs are covered.

Domain 2: Data Collection

The hospital is actively engaged in these data collecting activities:

• Collect demographic information, including self-reported race and ethnicity and/or social determinant of health (SDOH) info on majority of patients

• Train staff in culturally sensitive collection of demographic and/or SDOH info

• Input demographic and/or SDOH info collected into structured, interoperable data elements using a certified EHR technology.

Our take: It’s going to be critical to collect as much demographic and SDOH data as possible across the care continuum and store it securely. Leveraging technology and well-trained, culturally-sensitive staff will be key to securing honest information from patients about their health-related social needs.    

Domain 3: Data Analysis

The hospital needs to stratify key performance indicators by demographic and/or SDOH variables to identify equity gaps. Additionally, all this information needs to be included on hospital performance dashboards.

Our take: Having a robust analytics platform capable of identifying patient cohorts within hospital performance measures will be necessary. This level of information will provide visibility on inequities across different patient demographics and SDOH variables. Data collection under domain 2 will be critical for robust and meaningful data analysis.    

Domain 4: Quality Improvement

The hospital participates in local, regional or national QI activities focused on reducing health disparities.

Our take: Hospitals always do a great job at community events but we suspect there may be opportunity to focus on initiatives that specifically improve health equity. In addition, marketing these activities to vulnerable populations can improve awareness and engagement. Most local communities, especially the vulnerable populations, aren’t even aware of the hospital’s free wellness services. Additionally, this domain may encourage more hospitals to partner with other providers, or health and advocacy groups to reduce disparities in health.  

Domain 5: Leadership Engagement

Hospital senior leadership, including chief executives and the entire hospital board of trustees, demonstrates a commitment to equity through the following:

• Annual review of strategic plan for achieving health equity

• Annual review of KPIs stratified by demographic and/or social factors

Our take: We believe this will be the easiest to achieve since the plan and measurement should be defined within the first 4 domains.

The first pillar of the Centers for Medicare & Medicaid Services’ (CMS) Strategic Plan is health equity. This “Hospital Commitment to Health Equity” is part of the larger effort to encourage all healthcare providers to prioritize and address existing health disparities. While the CY2023 measure is largely a data request, we anticipate subsequent years will include process and outcome measures for health equity which could have payment implications.  

Working towards and achieving health equity is no easy feat, but there are processes and technology that can help move this quicker along the path and sustain it. We have found that the CMS framework for health equity and related data as well as the American Hospital Association (AHA) health equity roadmap are great resources to either begin or continue on your health equity journey.