Social, economic and geographic disadvantages create significant health disparities, such as lower quality of care and poorer health outcomes. To help improve these issues, the Centers for Medicare & Medicaid Services (CMS) revised the Global and Professional Direct Contracting Model under the new name Accountable Care Organization Model for Equity, Access, and Community Health (or ACO REACH) . This new model will test ways to address health care inequities by focusing on alternative payment structures that could better support accountable care delivery and care coordination.
What this means for the entire health care system is not yet fully known, but ACOs will find new policies to follow in January 2023. Chief among them will be the development of a health equity plan that should detail established health inequities and planned actions to correct such inequities. ACOs must also apply health equity adjustments to performance measures, collect data on demographic and social needs, and implement incentives for beneficiary engagement. When combined, the hope is not only to improve care delivery and coordination, but also to encourage beneficiaries to change unhealthy habits and behaviors.
Why the renewed interest in health disparities?
Health care disparities began to be recognized nationally nearly 20 years ago with the release of two Surgeon General’s reports documenting disparities in tobacco use and access to mental health care by race and ethnicity. In recent years, the differential impact of the pandemic on health outcomes and access to care based on socioeconomic factors has created renewed interest in health disparities.
To that end, CMS has introduced initiatives to address disparities that include racial and ethnic minorities, sexual and gender minorities, patients with disabilities, and beneficiaries living in rural areas. However, healthcare organizations often wonder where to start.
For one thing, current ACO attribution methodology can make it difficult to connect patients to their primary care providers or determine whether disengaged patients are even still part of their ACOs or Direct Assignors. Moreover, CMS provides participant lists only annually. This can leave ACOs working with outdated claims data and claim lines, making it extremely difficult to coordinate care, let alone improve the quality of care delivery.
Further complicating matters, many ACOs are comprised of independent practices contracted together with CMS, which may result in a lack of unified infrastructure, interoperability capabilities, or centralized resources for data aggregation and analysis. This can leave these ACOs struggling to understand how to keep costs low, calculate risk adjustment factor estimates, and identify members who need engagement efforts to improve health-related habits and behaviors (such as high-risk diabetics who could benefit from working with diabetes educators).
Finally, one of the key challenges in healthcare is engaging with the disengaged patient. If a health care organization cannot promptly establish a patient’s true clinical picture or effectively identify high- and low-risk populations, such errors can affect funding for needed care. Capturing the social determinants of health (SDoH) can help providers properly address risks outside of clinical settings. Certain demographic groups have an increased likelihood of developing certain conditions based on socioeconomic characteristics.
The benefits of greater equity in health care
As ACOs begin to capture increasing amounts of data and develop a deeper understanding of the communities they serve, opportunities for better patient engagement will naturally emerge. Health organizations must use all the information available to them to develop more impactful outreach programs—programs to improve health literacy and instill higher levels of trust in underserved communities. Trust has a direct impact on health outcomes, as people are more likely to seek care sooner when they trust their providers.
Addressing inequality can also increase the effectiveness of the health system to improve health outcomes. Risk adjustment combined with capturing SDoH factors may be helpful in identifying high-risk, disengaged patients, as delays in care disproportionately affect underserved community members and patients with chronic conditions. This, in turn, can lead to more accurate estimates of health status, predicted health care needs, and predicted costs of care. Take, for example, a Medicare Advantage patient with borderline type 2 diabetes and hypertensive heart disease. If this person receives regular care, the risk of developing other diseases is reduced.
After all, almost every patient with a chronic disease who does not receive regular care is at risk of progression of their condition leading to further complications. This scenario highlights the need to improve engagement efforts to ensure timely care delivery and optimize health management. It also allows healthcare organizations to determine health status that can be directly linked to the identification of preventive care and quality interventions that can reduce overall utilization.
With an increasing number of healthcare organizations participating in merit-based incentive payment systems, it is more important than ever to accurately determine the severity of a disease through proper diagnosis, documentation, and coding. Failure to properly code and apply the correct risk adjustment can affect ACO funding for care and the overall quality of care delivery, particularly those involving high-risk patients.
To effectively reduce disparities and improve the quality and coordination of care, government, providers, and healthcare organizations are beginning to collaborate on how best to address the factors leading to disparities between populations. ACO REACH is another step in the right direction. As all countries begin to implement the proper procedures to comply with the new policies, we will begin to improve health care inequities.
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