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In October of 2021, CMS’s Center for Medicare and Medicaid Innovation (CMMI) released their Ten-Year Strategic Plan which has five main pillars, one of which is Advancing Health Equity. They also outlined one of their key goals, to have all Medicare beneficiaries in some form of accountable care relationship by 2030. Achieving this goal will require reaching the most underserved populations, who are sadly the least likely to currently be enrolled in any sort of accountable care organization.
Model elements aimed at reducing healthcare disparities and at reaching underserved beneficiaries are a part of all recently released payment models, such as the Kidney Care Choices model which includes a stratified benchmark that rewards dialysis providers who treat more underserved beneficiaries. The ACO REACH model also includes a stratified benchmark, and goes a step further incorporating a required health equity plan and the collection of self-reported demographic and social determinants of health (SDOH) data.
Health equity is also wending its way into Medicare Advantage and the Medicare Shared Savings Program. For the first time, CMS is proposing the creation of a health equity index to be included as part of the Medicare Advantage Star Ratings formulas beginning in 2027. This Health Equity Index (HEI) is intended to reward contracts who narrow inequities faced by beneficiaries with certain social risk factors. These social risk factors would, at least initially, be beneficiary’s dual eligibility for Medicare and Medicaid or receipt of the Limited Income Subsidy.
Beginning in 2023, the Medicare Shared Savings Program (MSSP) is accounting for increases in the demographic portion of risk scores when calculating risk score caps, utilizing a similar methodology as ACO REACH. Every beneficiary has a risk score composed of two portions: demographic relative factors and disease relative factors. Demographic relative factors account for a beneficiary’s age, gender, dual-eligible status, and whether they initially obtained Medicare due to a disability. In calculating risk score caps in MSSP and ACO REACH, the cap will be relative to any increase or decrease in demographic relative factors. You can read more about how this works in our explainer on risk scoring in ACO REACH.