From moral obligation to strategic imperative: Health equity at a crossroads
By: Vimbai Mudimu, Andrew Borenstein and Ashlee Touzalin
The imperative of health equity
In healthcare, the spotlight on health equity has shifted over the years from a moral obligation to a strategic imperative. Notably, the COVID-19 pandemic brought to light stark disparities in healthcare access for underserved populations, prompting a heightened focus on health equity and placing the onus on health plans to adapt and innovate. Initially, health plans prioritized care management models to address these disparities. However, the recent proposed rule from the Centers for Medicare and Medicaid Services (CMS) mandates Medicare Advantage plans to incorporate health equity into utilization management (UM) activities, signaling a crucial shift. Consequently, health plans must proactively devise strategies that measure and manage equity, or they risk falling behind in the race toward a truly equitable healthcare system for all populations. This paper explores the CMS-proposed rules for health equity in UM, delving into how health plans can meet these mandates and further elevate their UM practices, seamlessly integrating health equity into their operational fabric.
CMS requirements for health equity in UM
In line with this renewed commitment to health equity, the CMS is shifting its focus to utilization management, and its potential impact on equitable access to care, proposing the following requirements:
1. Medicare Advantage plans must conduct a self-evaluation of their Part D UM criteria, specifically examining if prior authorization requirements disproportionately impact enrollees with social risk factors.
2. Payers must appoint a health equity expert to their UM committee. This expert should meet the qualifications through educational degree(s), credential(s) or relevant expertise.
3. The utilization management committee must conduct an annual health equity analysis of prior authorization (PA) usage, comparing metrics — approvals, denials and turn-around-times — for beneficiaries with and without social risk factors.
4. Payers must publicly report the results of their health equity analysis.
Measuring health equity
The proposed changes present a notable opportunity for health plans to take a proactive stance, crafting strategies that seamlessly and effectively align with the new rules, positioning them ahead of the curve.
Incorporating innovation
When measuring health equity in UM, it’s vital for health plans to adopt innovative and comprehensive approaches, acknowledging that this is just the first step towards advancing health equity in health care. This can be achieved through activities such as:
· Embracing data-driven analytics: Adopt a data-driven approach to measure and track health equity within existing UM programs by comparing key UM performance indicators across different member attributes, such as race, ethnicity, region and gender.
· Expanding data sources: Move beyond traditional claims and prior authorization data and acquire alternative sources such as third-party social determinants of health (SDOH) data to provide a more holistic understanding of inequities.
Building industry partnerships
In the pursuit of measuring health equity in UM, going at it alone isn’t the only path. Forging strategic partnerships with healthcare innovators holds substantial potential for expediting progress and elevating analytical capabilities. Here’s why joining forces is a winning strategy:
· Gain industry expertise and perspectives: Leverage the experience and knowledge of industry experts who have tackled health equity challenges head-on. Their fresh perspectives and proven approaches can guide your efforts. Additionally, external partners often possess access to comprehensive benchmark data and proprietary insights unavailable internally. This rich information empowers you to make data-driven decisions and target interventions effectively.
· Optimize internal resources: Let specialized organizations manage specialized tasks while you concentrate on your core competencies. This ensures efficient operations and avoids stretching your internal capacity thin.
· Speed-to-market: By partnering with organizations that have already developed and validated solutions, you can bypass lengthy internal development stages. This translates to swift implementation and quicker impact.
These partnerships offer a wealth of benefits, including access to proven tools like ZS’s Smart UM Optimizer. This powerful tool efficiently assesses the impact of PA programs on diverse demographic and geographic groups, streamlining the analysis process and providing valuable insights. By leveraging such pre-developed solutions, health plans can achieve a quick and seamless implementation, minimizing disruption to existing workflows while accelerating their progress towards health equity.
FIGURE: ZS’s Smart UM Optimizer equity and parity user interface
Exceeding CMS mandates
The CMS rules regarding health equity measurement is just the beginning, as an increasing emphasis on health equity continues to emerge. Therefore, it’s imperative for payers to transcend these rules to not just meet the requirements, but to surpass expectations and become industry leaders in ensuring equitable care results in optimal outcomes for their members. One such approach is leveraging SDOH datasets, AI and machine learning (ML) to identify and predict areas at risk for higher emergency room (ER) utilization and inpatient utilization. By collaborating with these communities and implementing targeted UM interventions, health plans can address the issue and achieve significant medical cost savings. For instance, in areas with marginalized communities that have limited healthcare infrastructure and high rates of ER and inpatient utilization, health plans can proactively identify individuals at risk through predictive modeling and design targeted, individualized health equity interventions tailored specifically towards the community’s needs. This approach helps mitigate unnecessary utilization and improves access to care.
A call to action
The coming wave of CMS scrutiny on health equity in UM presents a major opportunity. This is a call to action for payers to seize this opportunity, by prioritizing health equity, embracing data and to partner with industry experts and work hand-in-hand with communities to build a healthcare system that truly serves all.
