The U.S. government has recently amplified its commitment to health equity, as evidenced by the release of documents such as the “CMS Framework for Health Equity 2022-2032,”1 “The U.S. Playbook to Address Social Determinants of Health,”2 and several recent pieces of legislation.3 Medicare Advantage organizations (MAOs) with health equity expertise are best positioned to understand and implement this overall initiative, as some pieces of this legislation explicitly require MAOs to incorporate health equity expertise. In this white paper, we expand upon our prior discussion of recent CMS initiatives and provide actions MAOs can take to secure health equity expertise.
What is health equity expertise?
The Centers for Medicare and Medicaid Services (CMS) defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factor that affect access to care and health outcomes.”4
Embedded in CMS’s proposed health equity self-evaluation of each MAO’s Part D utilization management criteria is the requirement for every utilization management committee to include a member with expertise in health equity.5 CMS defined this expertise broadly by educational degree(s), credential(s), and/or relevant health equity expertise, including experience conducting studies to identify disparities among different population groups, experience leading organization-wide policies, experience in programs or services to achieve health equity, or experience leading advocacy efforts to achieve health equity. Possible relevant educational degree(s) and credential(s) currently include:
- Master of Public Health with concentration or focus in health disparities, health (in)equity, social justice, and/or human rights
- Graduate Medical Education health equity track in residency; health equity fellowship
- Certificate in health disparities, health (in)equity, social justice, and/or human rights
Note that this list is not meant to be exhaustive and is expected to evolve with the discipline of health disparities and health equity.
Action 1: Follow CMS initiatives and utilize resources
MAOs should have a process in place to maintain awareness of all CMS requirements related to health equity expertise to ensure compliance.
One recent example, CMS’s “Annual Health Equity Analysis of Utilization Management Policies and Procedures,” is currently a proposed rule that, if finalized, would require each MAO to include a member with equity experience on its utilization management committee by January 1, 2025.6 MAOs should follow the progression of this proposed rule, and any future similar rules, over the coming months to ensure compliance with any health equity expertise requirements.
CMS offers many resources with a health equity focus. CMS maintains a page dedicated to health equity technical assistance, including research reports and data sources, which is accessible here. Additionally, CMS makes available research posters from past conferences, accessible here.
Action 2: Seek and cultivate real-world experience
Many MAOs will seek to hire or contract with staff who can fulfill the requirement to have staff with expertise. However, the criteria of “relevant health equity expertise” may be challenging to qualify and/or rate objectively among candidates eligible for a position(s) on the utilization management committee. Generally accepted metrics of expertise beyond degree(s) and credential(s) include grant acceptance and peer-reviewed journal article publication rates. In the context of health disparities and health equity work, however, these metrics have been accompanied by concerns that work performed by non-white researchers is not being properly attributed to them, nor cited by white researchers.7
In addition to learned expertise, real-world and/or lived experience should be harnessed, as should representation of the populations CMS has defined for analysis, including low-income/dual-eligible and/or eligible disabled status.8 Individuals with direct work experience aligned to an MAO’s needs, individuals who have experienced these factors, and beneficiaries themselves and/or information collected directly from them, could prove invaluable in providing insight where existing data and information may be lacking.
MAOs may need to identify more than one health equity expert to add to their utilization management committees or to assemble a diverse team(s) that provides input to the committee via one or more individuals. In this case, the MAO should look to:
- Include individuals with different demographic backgrounds, such as personal or professional work experience with low-income/dual-eligible and/or eligible disabled status, in particular.
- Include various stakeholders and perspectives, such as personal or professional work experience providing care to beneficiaries, caretaking for a beneficiary, working as a broker, and processing and/or analyzing claim data, healthcare finance(s), etc.
- Supplement with information collected directly from beneficiaries (e.g., focus groups, member advisory committees).
Action 3: Gather insightful data
Addressing healthcare disparities requires actionable data. Data at a geographic unit of analysis, such as county, or even ZIP Code, can provide fruitful insight. However, important patterns may be overlooked if analyses are not also performed at the individual level.9 Income, dual eligibility, and reason for eligibility status are available for each beneficiary in the Monthly Membership Report (MMR).
Other data points may include those shown in Figure 1.
Figure 1: Other data
| Race/ethnicity | Note that this variable often serves as a proxy for structural/systemic racism and is also available in the MMR. |
| Rurality | These variables may be defined by linking ZIP Code to a classification system, or directly for a nationally representative sample of beneficiaries in the Medicare Current Beneficiary Survey. |
| Income level | |
| Access to transportation | |
| Access to internet |
Action 4: Analyze data appropriately to ensure findings are sound
After gathering data, expertise is needed to review the analytical approach before it is implemented, to critique data sources relative to the intended analysis, and to advise on the presentation of findings. Standards for health disparities and health equity work continue to evolve, but the following offers a framework:
- Analytical approach
- In addition to health equity expertise, include statistical and actuarial expertise. This may necessitate the use of external resources.
- Association does not indicate correlation and neither association nor correlation indicate causation.
- What confounding variables or other hidden bias might explain findings?
- Data sources
- Does the data capture the exposure (intervention) and outcome?
- How is the sample representative of the larger population of interest?
- Presentation of findings
- If summarized another way, do the findings change?
- Labels and order matter: the focus of the findings does not always need to be on the majority.
- Narrative accompanying findings is written in an inclusive and culturally competent style.
- How might findings be misinterpreted? What can be done to prevent unintended conclusions from being drawn?
An organization-wide committee or oversight function may become necessary as health disparities and health equity work expands. This function can serve to vet proposed work, ensure consistency in methodology and terminology, and consider the macro and long-term impacts findings may have on population(s), intended and unintended.
Conclusion
The four actions outlined in this paper are not an exhaustive list of approaches for securing health equity expertise. It is critically important that MAOs keep up to date with all relevant legislation, as requirements may be refined or added. Equity-focused efforts are becoming a larger area of emphasis in regulations and guidance, making obtaining expertise a necessity for MAOs.
1 CMS. CMS Framework for Health Equity 2022–2032. Retrieved January 12, 2024, from https://www.cms.gov/files/document/cms-framework-health-equity-2022.pdf.
2 White House (November 2023). The U.S. Playbook to Address Social Determinants of Health. Retrieved January 12, 2024, from https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-3.pdf.
3 Niakin, K., Russo, E., & Klein, M. (December 8, 2023). What Medicare Plans Should Know About CMS’s Recent Health Equity-Focused Initiatives. Milliman White Paper. Retrieved January 12, 2024, from https://www.milliman.com/en/insight/recent-health-equity-focused-initiatives-from-cms-medicare-plans.
4 CMS. Health Equity Terminology and Quality Measures. Retrieved January 12, 2024, from https://mmshub.cms.gov/about-quality/quality-at-CMS/goals/cms-focus-on-health-equity/health-equity-terminology.
5 The full text of the proposed rule is available at https://public-inspection.federalregister.gov/2023-24118.pdf.
7 McFarling, U.L. (September 23, 2021). “Health equity tourists”: How white scholars are colonizing research on health disparities. STAT. Retrieved January 12, 2024, from https://www.statnews.com/2021/09/23/health-equity-tourists-white-scholars-colonizing-health-disparities-research/.
8 ASPE.HHS.gov. Engaging People With Lived Experience to Improve Federal Research, Policy, and Practice. Retrieved January 12, 2024, from https://aspe.hhs.gov/lived-experience.
9 Azar, K.M.J. et al. (February 17, 2023). ACO Benchmarks Based on Area Deprivation Index Mask Inequities. Health Affairs. Retrieved January 12, 2024, from https://www.healthaffairs.org/content/forefront/aco-benchmarks-based-area-deprivation-index-mask-inequities.