Health Equity, Quality Measurement, and the Future of All-Payer Data

Over the past two years, the Centers for Medicare & Medicaid Services (CMS) has tried to determine how best to adjust quality scoring for beneficiaries within Accountable Care Organizations (ACOs) without penalizing providers treating communities with an increased risk of poor health outcomes. CMS’ latest Physician Fee Schedule (PFS) proposed rule includes a health equity adjustment to quality performance, suggesting the federal agency recognizes inequities exist among ACOs serving safety-net populations, but is it the right approach?Currently, Medicare ACOs – groups of healthcare providers who collectively coordinate care for patients to improve quality and manage costs – are accountable for quality performance on certain measures for their Medicare-aligned population. In the future, barring any changes, CMS will require reporting on quality performance across all-payers – meaning Medicare will reward or penalize providers based on quality performance for all their patients. This is in keeping with the goal that in order to make the investments necessary to improve care, a provider must be committed to that change across the entire population. One concern is that reporting all-payer data may put safety-net providers at a disadvantage relative to ACOs who are not serving such populations.We sat down with Mount Sinai Health System’s Senior Director of Government Channels, Maria Alexander, to examine how the current rules and proposed changes may impact providers caring for large, historically underserved populations.“When you base payment on all-payer quality performance, you are likely to reward ACOs that treat a more affluent, commercially-insured population with fewer health-related social needs – and fewer barriers to high quality care – and take money away from ACOs that are made up primarily of other safety-net providers that work with underserved populations,” Alexander said. “With [the PFS] proposed changes, CMS states that they want to reward ACOs for providing high quality care to underserved populations, but just because an ACO has a good quality score across its full all-payer population, doesn’t mean that it is providing high quality care to underserved populations or that it is doing anything to address health disparities.”

Data Reporting Complexities

All-payer data is collected through Electronic Clinical Quality Measures (eCQMs) or MIPS Clinical Quality Measures (CQMs) – tools for tracking the quality of health care services pulled from data within a provider’s electronic health record (EHR). ACOs currently have the option of using a portal known as the CMS Web Interface to upload data on a sample of attributed Medicare ACO patients, but reporting through the portal often requires hiring additional staff to conduct chart extraction and submission. eCQMs are supposed to make the process simpler for practices, which is part of the reason CMS has initiated a new requirement for ACOs in the Medicare Shared Savings Program to transition to this tool by 2025.While in the long run, it may be beneficial to move away from manual reporting like the CMS Web Interface, there are significant upfront, and potentially ongoing, costs for ACOs to figure out how to combine and de-duplicate data across a variety of EHRs within their network. Safety-net providers are less likely to have the resources to invest in that reporting infrastructure. When combined with the potential for lower performance scores among those serving disinvested patient populations, this may discourage ACO participation from safety-net providers.Many ACOs offer additional services for patients to help with their care – like chronic care management and resources to address social needs – so overlooking safety-net providers over concerns about negatively affecting their quality performance could ultimately hurt patients. To mitigate this potential inequity, in the proposed rule, CMS plans to use the Area Deprivation Index (ADI) to identify underserved neighborhoods through national deciles. Evidence shows that using national deciles does not always accurately identify existing disparities because it isn't granular enough – this means that underserved neighborhoods within a high cost of living area may fall into the advantaged percentiles in the ADI.A better way to pinpoint vulnerable communities is to first collect quality data stratified by payer type to create a baseline for identifying and targeting specific populations to understand quality performance and set incentives to address disparities. Once the data is collected, CMS should begin weighting metrics by payer type to provide resources to safety-net providers more equitably. Gathering sufficient detail in the all-payer data is not an easy task, but it is a critical first step to addressing equity issues before tying shared savings payments to it.“We don’t want CMS to set a lower bar for quality of care for lower income patients or people of color, but we know there are systemic issues both inside and outside of health care that lead to worse health outcomes among certain communities,” said Alexander. “If we tie payment to quality performance without understanding those differences, I worry that we will exacerbate disparities by taking resources away from providers and communities that need them most.”For providers who may be unsure what to do before the 2025 deadline to migrate to all payer eCQM reporting, Alexander recommends looking at the population data as soon as possible to see how it will affect ACO performance and determine areas for improvement before the all-payer reporting is required.Aurrera Health Group is offering baseline health equity assessments to support ACOs as they try to understand readiness and capacity to identify and address disparities that exist within their population and plan interventions. To learn more, contact the Aurrera Health Medicare team at medicare@aurrerahealth.com.Maria Alexander is the Senior Director of Government Channels for Mount Sinai Health System, where she oversees Mount Sinai’s participation in the Medicare Shared Savings Program and advises on other government payer programs and policy. Prior to joining Mount Sinai in 2018, Maria spent six years at the Centers for Medicare & Medicaid Services (CMS), most recently as a Division Director in the Center for Medicare & Medicaid Innovation (CMMI). Maria holds a BA from Tufts University.

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Authors

Erin Connolly [Senior Policy Consultant]