Improving Health Equity through Whole-Person Care

In March of 2022, the Centers for Medicare & Medicaid Services (“CMS”) released the 2021-2030 National Health Expenditure (“NHE”) report, prepared by the CMS Office of the Actuary, that presents health spending and enrollment projections for the coming decade.¹ In this report, CMS projected that total healthcare spending will reach $6.8 trillion in 2030.² CMS is forecasting that approximately one of every five dollars spent in the U.S. economy will be healthcare spending (19.6% of GDP).³ They also forecast that the fastest growing program will be Medicare, with an average of 7.2% over 2021-2030, and the drivers of this growth are expected increases in utilization coupled with population demographics.⁴

The U.S. population is aging. According to the Congressional Budget Office’s (“CBO”) January 2024 report “The Demographic Outlook: 2024 to 2054,” there are currently 60.8 million individuals aged 65 and older, representing 17.8% of the total population.⁵ By 2030, those figures grow to 70.6 million, representing 19.8% of the population, and continue to grow for several years thereafter.⁶

The CBO is also forecasting the Federal Debt to continue increasing.⁷ In the CBO’s February 2024 report “The Budget and Economic Outlook: 2024 to 2034,” the CBO reports that at year-end 2023 the Federal Debt as a percentage of GDP is estimated to be 97.3%.⁸ By 2030, that is forecasted to grow to 108.7%, and it will exceed 125% of GDP sometime in 2038.⁹

What do all these projections tell us? Government spending, including spending on healthcare programs, may be unsustainable. At some point, programs may need to cut benefits, which will be highly unpopular, or the healthcare industry will need to implement programs that are effective at keeping members healthier longer and ultimately reduce the overall cost of care. This is one reason CMS is implementing its Health Equity initiatives.

CMS has a stated goal of increased accountability to improve health disparities for Medicare Advantage Organizations (“MAO”), especially for members with Social Risk Factors (“SRFs”).¹⁰ A 2016 Report to Congress by the United States Department of Health and Human Services (“DHHS”) noted that performance on several HEDIS measures for Dual-Eligible members fell significantly below that of non-Dual members.¹¹ For example, for Measure C01: Colorectal Screening, Dual-Eligible members scored 60.3% compared with non-Dual members at 75.7%.¹² Another example is C13: Osteoporosis Management in Women Who Had a Fracture, where Dual-Eligible members scored 21.8% compared to 29.1% for non-Dual members.¹³

The report recognized that social risk factors impact member health, and significant gaps exist based on income, race, ethnicity and community environment. It also acknowledged the need to better understand the relationship between social risk and performance on these programs to properly align value-based programs with their intended goals.

Importance of Closing Health Disparities for MA Members with Social Risk Factors

CMS currently has three segments of the Medicare population that it uses to define and identify members with SRFs: members who are a) eligible for LIS subsidies, b) disabled or c) Dually Eligible for both Medicare and Medicaid benefits (Dual-Eligible).

The demographics and social characteristics of Dual-Eligibles show that this population has clinical, behavioral health and social needs that vary significantly from the non-Dual Medicare population. Understanding these differences is important, as they make up 19% of the total Medicare population but account for 34% of the spending.¹⁴

Some key characteristics that differentiate Dual-Eligible members from the non-Dual-Eligible Medicare population include¹⁵

• Racial diversity, with a materially higher percentage of people of color
• A larger percentage of members living alone or with someone other than a spouse
• Lower levels of education, with the majority of Dual-Eligibles having a high school education or less¹⁶

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Initiatives to Incentivize Payers to Focus on Health Equity

In response to disparities between members with SRFs (particularly Dual-Eligibles) and those without, CMS and the National Committee for Quality Assurance (“NCQA”) are implementing several initiatives designed to improve outcomes and reduce health disparities:

Changes to the Star Reward Factor: The New Health Equity Index

As outlined in the Final Rule for Contract Year 2025, CMS is tying improvements in health disparities for members with SRFs and replacing the Medicare Advantage Reward Factor with the Health Equity Index (“HEI”) reward.¹⁸

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The HEI is structured to:¹⁹

• Give a Star rating bump to MAOs who perform better than peers in improving a sub-set of Star, Healthcare Effectiveness Data and Information Set (“HEDIS”) and Consumer Assessment of Healthcare Providers and Systems (“CAHPS”) measures for members with SRFs
• Rank MAOs’ performance for each HEI measure (yet to be announced by CMS) to award measure-weighted points with more points awarded to top MAO performers; this scoring method is designed to reward MAOs that have strong outreach and engagement efforts for these harder-to-engage members
• Award an MAO’s actual HEI Reward factor based on two components: the HEI Score described above and the percentage of the plan’s membership who have Social Risk Factors
• Include data from the 2024 and 2025 measurement periods and apply it to the 2027 Star Ratings

Plan’s Percentage of Members with SRFs20	Potential HEI Reward Factor
Percent of members with SRFs for the plan is ≥ the contract level median for SRF enrollment across all MAO contracts	0.4 X HEI Score
Percent of members with SRFs for the plan is ≥ 50% of the contract level median but < the median for SRF enrollment across all MAO contracts	0.2 X HEI Score
Percent of members with SRFs for the plan is < 50% of the contract level median for SRF enrollment across all MAO contracts	ZERO HEI Reward

New CMS Requirements for Health Risk Assessments for Dual-Eligible Special Needs Plans (“D-SNPs”) and other Special Needs Plans (“SNPs”)

CMS’ Final Rule requires D-SNPs to include new elements in health risk assessments (“HRAs”), including standardized questions regarding housing, food and transportation insecurities. The final rule includes examples of standardized questions based on the Accountable Health Communities Health-Related Social Needs Screening Tool.²¹

CMS Enhanced Requirements for all MAO Members

The CMS Final Rule includes requirements designed to increase Medicare beneficiaries’ access to health and behavioral health services.²² These requirements include:

• Requiring Culturally Competent Care for members with limited English proficiency, those identifying as LGBTQ, those who live in rural areas and areas of high deprivation or those adversely impacted by persistent poverty and inequality
• MAOs must promote digital health literacy to improve telehealth utilization rates
• MAOs must improve access to behavioral health services

New HEDIS Measure: Social Needs Screening

Starting with Measurement Year 2023, NCQA introduced a new HEDIS® measure, Social Needs Screening (“SNS”), which will measure the number of members who have at least one screening for food, housing or transportation needs. For those who have a social need, MAOs must conduct an intervention within 30 days to address the need.²³

How a Whole-Person Care Model Aligns with Health Equity

Historically, the healthcare system has focused on controllable aspects of an individual’s overall health, such as diet, exercise and sleep patterns. There is growing recognition that health outcomes are also impacted by less controllable variables such as where a person is born, where they live, their education, their work and their affluence. All of these factors contribute to the gaps in the quality of care described above.

Medicare’s introduction of new initiatives, such as the HEI reward factor, are designed to incentivize new approaches to care, including ensuring that social factors are acknowledged and SRFs are addressed when providing for the clinical health needs of at-risk individuals.

Whole-Person Care is a holistic model that considers many of the variables that could impact a member’s health. The concept of Whole-Person Care has existed for decades, but use of the model may be growing as the health system recognizes that health is impacted by life — a member worried about losing their home or feeding their family will likely forego needed care.

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Whole-Person Care acknowledges that members’ care needs are not homogenous and is designed to improve health outcomes across five domains of personal well-being:

• Physical health
• Emotional or behavioral health
• Spiritual-cultural preferences
• Social supports: family, friends and community
• Environment: housing, transportation, nutrition, education, employment and safety

Success requires a great deal of coordination and information-sharing among care-providing disciplines. In addition, Whole-Person Care includes an element of member involvement — a willingness to seek care and engage in their health outcomes.

Engaging Members with Social Risk Factors

High-performing MAOs work continuously to optimize performance. Key performance drivers include member satisfaction and retention, closure of care gaps and quality measures that optimize risk and Stars reimbursement and improve affordability. Going forward, best-in-class MAOs will also work to optimize additional skills including:

• Improving engagement rates for members with SRFs, resulting in improved access to preventive care, increased closed care gaps and higher levels of care management and care coordination
• Increasing the capabilities and overall accessibility of care outside of a traditional office setting; expanding in-home care capabilities will be especially critical to improving engagement
• Screening for and addressing social determinants of health: housing, food insecurity, transportation and digital literacy
• Ensuring that members receive increased access to culturally competent care

Despite MAO efforts, segments of members have challenges interacting with the healthcare system for a number of reasons. Dual-Eligibles make up a significant segment of members with SRFs and on average, Duals are less educated. As such, engaging these members may require healthcare organizations to communicate with a different message. One-third of Dual-Eligibles have a behavioral health diagnosis, which requires different resources for effective engagement. In addition, these members are almost twice as likely to live alone or with someone who is not a spouse, increasing the chance that they do not have reliable support when caring for themselves.

Improving outcomes and removing barriers requires that both payers and providers understand member needs and, for lack of a better term, “understand the audience” — what care the member needs and actions the member is willing to take as part of their care. To maximize engagement rates, organizations can develop analytics to better understand member contact and communication preferences — what channels and at what times the member would prefer plans and providers reach out to communicate. Establishing this understanding can also help predict how likely a member is to address a specific health need during an encounter as well as the place of service where a member would prefer to receive care. Once they have this data, organizations can act to increase flexibility and expand access options, allowing the member to receive care at the location that is most convenient and comfortable.

Leveraging Home Care to Address Health Conditions and Health-Related Social Needs

In-home care is critical in terms of increasing member engagement. It provides members with comfort and convenience, and it gives providers and health plans a deeper understanding of a member’s needs and risk factors.

When a member is in a doctor’s office, a member with needs can self-report that they are taking their medications as prescribed and eating healthy meals. But when in the member’s home, first-hand observation of full pill bottles and little food in the refrigerator allows a provider to act immediately on that need. The visual information a provider learns in the home about care support, home safety and even a member’s social interaction can be of significant value to a care provider and may never be raised in an office setting.

Currently, many MAOs leverage in-home providers to perform assessments that provide Annual Wellness Visit-related services to plan members to capture diagnoses data supporting MA risk adjustment, and some of those also attempt to close HEDIS measures for Stars. However, utilizing in-home care solely for assessment data is limiting — it restricts the value that an in-home healthcare organization can provide to a health plan and its members.

A better approach may be to maximize the value of the time a member is willing to share when they have allowed a provider into their home. An in-home encounter can and should create value through:

• Detailed annual wellness visits
• Assessments of open HEDIS measures for quality programs
• Health Equity screenings for potential risks in housing, food, loneliness, etc., and make referrals to community service organizations
• Home safety evaluations
• Assessments of limitations in Activities of Daily Living
• Coordinating with health plan care management programs and other care coordinators or case managers
• Monitoring known chronic conditions following a member’s care plan and potentially acting as an extender to the member’s provider team

The following is an illustrative list highlighting examples of the services that can be performed in-home and can provide health plans with a road map to improve health equity measures and overall plan performance.

Domain	In-Home Care Solution
In-home Assessments for risk adjustment and quality programs	Conducting comprehensive in-home health assessments and annual wellness exams to assess known and suspected chronic conditions and closing any open HEDIS measures In-home screening and laboratory testing: FIT, HbA1c, Urine Albumin and Kidney Health Evaluation (“KED”), etc. Facilitating medically necessary Telehealth visits from member’s homes Home safety assessments Conducting medication reconciliation and adherence counseling
Social Determinant of Health (“SDOH”) Screening and Interventions	Screening for SDOH using CMS compliant tools24 Developing an individualized Whole-Person Plan-of-Care, including: Biopsychosocial Cultural and spiritual needs Family and other supports Social risk factors (housing, food and transportation insecurities) Connecting members to community resources and health plan benefits as needed to address identified social support needs Follow-up after home-visits and community resource referrals to ensure SDOH issues are remediated
Care Coordination and Extension	Coordinating transitions of care when members are discharged from a facility Care coordination with treating providers Coordination with health plan Care Management including behavioral health care management programs Facilitating referrals to necessary care providers including behavioral health and finding a member a PCP if necessary Follow-up to ensure compliance with care plan recommendations and to ensure referrals have been satisfactorily completed
Member Education	Providing member education on health conditions and medications Providing members with CMS-required information about the digital resources and other supplemental benefits that are available as part of their MA plan Providing member education on available resources such as: Community Resources for SDOH and other resource needs Available Health Plan benefits including expanded benefits and care management programs