Leveraging Medicare to Advance Health Equity | Health Disparities

Leveraging Medicare to Advance Health Equity | Health Disparities | JAMA

By FYH News Team

Published on April 21, 2022

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Profound health inequities have persisted in the United States for generations, and many of these inequities were laid bare by the COVID-19 pandemic that is disproportionately and adversely affecting people who are American Indian or Alaska Native, Black, or Hispanic; people with disabilities; and older adults. As the largest payer of health care in the United States, covering 63 million people in partnership with more than 1 million clinicians and 6000 hospitals, Medicare has played a catalyzing role in addressing inequities and advancing civil rights. For example, in the 1960s, Medicare required hospitals, nursing homes, and other Part A provider organizations, such as home health agencies and hospices, to desegregate as a condition of participation. Even with this important legacy, there remains a multitude of health inequities affecting people with Medicare.1 A recommitment toward addressing equity cannot wait.

For the Centers for Medicare & Medicaid Services (CMS), health equity means the attainment of the highest level of health for all people, whereby every person has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes. Consistent with the updated health equity strategy of CMS, the vision for health equity in Medicare is 2-fold: improving operations and implementing policies that advance health equity.

Improving Medicare Operations to Advance Health Equity

To advance health equity through improved operations within Traditional Medicare and Medicare Advantage and Part D programs, all work will be approached through a health equity lens. Physicians and other health care professionals have seen firsthand that when the health care system does not work for patients, individuals with complex health and social needs are the ones most likely to have delays in care, not receive needed care, and to have worse outcomes as a result. It is essential that health care is reliable, easy to navigate, high quality, and comprehensive for all patients, particularly those who may not have the ability to advocate for themselves. As such, Medicare is engaging people with Medicare from underserved communities and the clinicians and organizations who serve them, whose voices are not always heard in the efforts to improve health care.

The Medicare commitment to health equity means stronger oversight to ensure that people with Medicare can quickly and easily access the care they need, and that the information they receive about their conditions and care is easy to understand in their native languages. For example, CMS has proposed requiring multilanguage inserts in all required Medicare Advantage plan communications that direct people to further free language and translation service.2 CMS is also proposing new metrics to assess how health care providers make the internal operational changes needed to promote health equity, for example, whether hospital leadership annually reviews strategic plans for achieving health equity.³

Medicare must make its programs more accessible for the people and communities that experience inequities. For example, low-income older adults and adults with disabilities can receive access to financial assistance with premiums and cost-sharing through the Medicare Savings Programs. These programs help millions of people with Medicare access high-quality, affordable health care, yet only about half of those who are eligible for these benefits enroll. Last year, Medicare redoubled efforts to broadly communicate about these important programs and enrollment has already increased significantly, but more work remains to be done.

Improving Medicare operations also requires collection and analysis of reliable demographic information, establishing an important foundation to monitor progress toward advancing health equity. Recently, CMS took steps to include race and ethnicity as optional questions as part of Medicare Advantage enrollment, and CMS is continuing to explore the collection of additional demographic information in Traditional Medicare. With these data, Medicare can work both internally and with external researchers to identify care gaps to inform future policy development. This leads to the second area of work: specific Medicare policy interventions to address disparities and promote health equity.

Medicare Policy Interventions to Promote Health Equity

More than 20 years after the landmark Institute of Medicine (now the National Academy of Medicine) study “Crossing the Quality Chasm,” health care quality leaders have concluded that “there is no equity without quality, and there is no quality without equity.”4 A tremendous opportunity exists to infuse health equity into Medicare’s payment incentive programs with a more deliberate and aligned approach across the various programs in which health care quality is measured. Building from research that has demonstrated Medicare-Medicaid dual eligibility as an important predictor of both social risk and adverse health outcomes,⁵ CMS sought comment on how to stratify quality measures in hospital and skilled nursing facilities by markers of social risk to better identify and encourage the reduction of disparities.³ CMS also sought comment on a new health equity index to identify and reward Medicare Advantage and Part D plans that deliver high-quality care to underserved populations.⁶ These efforts are part of a broader strategy to use quality measurement as a tool to focus clinicians on improving equity across all CMS programs.

CMS is pairing these quality-related efforts with policy actions to advance health equity through efforts that address health-related social needs. These social needs are particularly pronounced for persons in rural areas that lack access to social services and in other underserved communities. Screening to identify social needs is the first step, and so CMS recently proposed requiring special needs plans (special types of Medicare Advantage plans for people who are dually eligible, live in an institution, or have certain chronic conditions) to screen for social needs as part of their health risk assessments,2 and CMS has also proposed new quality measures to assess how often hospitals are doing so.³ Moving beyond screening, CMS is considering how to ensure appropriate follow-up when people screen positive for health-related social needs, including exploring how to better support addressing these needs in partnership with community-based organizations and other agencies.

The push by CMS toward delivery system transformation also includes a focus on equity. Accountable care organizations link together networks of clinicians in a coordinated way that can be beneficial for individuals with complex health and social needs.7 Accountable care organizations have incentives to address inequitable care gaps and social factors that lead to poorer health outcomes, and Medicare is looking to build on this foundation by exploring new policies to support accountable care organizations in rural and other underserved communities. Additionally, following congressional action, CMS is expanding funding for medical residency positions—one of the largest increases in 25 years—and is giving priority to hospitals that serve rural and other underserved areas.⁸ CMS has also made significant strides in addressing geographic barriers to care by permanently allowing people in their homes to access telehealth services (including audio-only telephone calls) for behavioral health conditions.⁹

The health care system can wait no longer to rectify the long-standing health inequities that adversely affect people in the United States, and the policies discussed herein are a start. Addressing health inequities meaningfully and with lasting benefit is beyond the ability of any 1 clinician, any 1 health care center, any 1 payer, or any 1 agency. It is the collective responsibility of all to work together to ameliorate the inequities present in the health care system and in society that have been reinforced for generations. Medicare can and will take a leadership role in mobilizing and catalyzing the work necessary to advance health equity. Infusing health equity into everything that Medicare does—both through improving operations and implementing equitable policies—requires every clinician and health care entity that provides services in Medicare and every Medicare Advantage plan to start the hard work of advancing health equity now. People with Medicare deserve nothing less than a health care system that provides patient-centered, equitable, high-quality care.

Corresponding Author: Douglas B. Jacobs, MD, MPH, Centers for Medicare & Medicaid Services, 7500 Security Blvd, Baltimore, MD 21244 (Douglas.Jacobs@cms.hhs.gov).

Published Online: April 21, 2022. doi:10.1001/jama.2022.6613

Conflict of Interest Disclosures: None reported.

Additional Contributions: We acknowledge Michelle Schreiber, MD, Adam Richards, Kristi Martin, MA, MPA, Megan O’Toole, MPA, Erin Richardson, JD, MA, and Jonathan Blum, MPP, for reviewing and commenting on the manuscript; LaShawn McIver, MD, MPH, and Dora Hughes, MD, MPH, for having conceptual discussions with the authors; and Raymond Thorn, MA, for helping with review. All are with the Centers for Medicare & Medicaid Services and did not receive compensation.

Additional Information: Dr Jacobs is an assistant professor at Penn State Milton S. Hershey Medical Center.

Centers for Medicare & Medicaid Services. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital perspective payment system and proposed changes and fiscal year 2023 rates; quality programs and Medicare promoting interoperability program requirements for eligible hospitals and critical access hospitals; costs incurred for qualified and non-qualified deferred compensation plans; and changes to hospital and critical access hospital conditions of participation. Federal Register. Published April 18, 2022. Accessed April 18, 2022. https://public-inspection.federalregister.gov/2022-08268.pdf

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