On July 10, 2023, the Center for Medicare & Medicaid Innovation (CMMI or “Innovation Center”) released a White Paper, Assessing Equity to Drive Health Care Improvements, outlining their analysis and assessment of health equity incorporation in model designs and evaluations. CMMI supports the development and testing of innovative health care payment and service delivery models. These innovation models are designed to improve quality of care and patient outcomes while reducing or maintaining program costs.[1]
In 2021, CMMI launched its strategy refresh (the “Strategy”) with the goal of achieving equitable health outcomes through high-quality, affordable, person-centered care. One of the main objectives of the Strategy is to embed health equity in every aspect of CMMI models and increase focus on underserved populations.[2] In order to measure the progress of this effort CMMI began requiring participants in all new models to collect and report the demographic data of their beneficiaries, including data on social needs and social determinants of health.[3] Prior to the Strategy, Innovation Center models did not have an explicit health equity focus. Despite this, these models still offer valuable information related to program design, implementation and evaluation.[4] The Innovation Center conducted an analysis of all model evaluations underway or recently completed in order to track the progress of the Strategy commitment to health equity.
The models included in the Innovation Center’s analysis were divided into two groups. Group 1 consisted of models designed to address the needs of underserved enrollees. Group 2 was comprised of models that included underserved enrollees but are designed to address the population at large. CMMI examined the following three domains in each evaluation report: the reach of the model, the ability to assess impact, and the experiences of beneficiaries. Quantitative data was collected from Medicare and Medicaid claims, other administrative data, health-related social needs screening results, and surveys. Many of the evaluations included primary data, such as perspectives from individuals enrolled in Medicare and Medicaid.
The analysis found that many of the models lacked sufficient data when assessing health equity. Data challenges included small population sizes, missing data on key elements (e.g., race and ethnicity), and categorization that does not capture critical subpopulations. CMMI reported three main takeaways about its health equity data:[5]
- The variable quality of race/ethnicity data in Medicare and Medicaid claim data presents a challenge for understanding whether models reach and enroll underserved individuals. CMMI noted that there was missing data for a substantial proportion of individuals in Medicare and Medicaid as well as limited racial and ethnic categories.
- Model designs have not always considered needs specific to underserved individuals.
- Model designs that do not prioritize the inclusion of underserved individuals may have small sample sizes for these populations that limits the ability to draw conclusions.
In order to accurately assess the progress CMMI has made on the Strategy objectives, the Innovation Center must incorporate health equity data collection practices into every element of innovation model design. Opportunities for improvement include linking data sets to fill information gaps, targeted sampling in primary data collection, and identifying or developing data collection instruments and protocols that account for health equity. As mentioned in the review, CMMI is considering other promising practices for future use such as incorporating health equity priorities from the start of model design; exploring additional incentives or recruitment strategies in more diverse areas and/or those serving patients with high levels of social need; requiring participating entities to collect specific measures or beneficiary-level information; and utilizing multiple research methods to assess the impacts on and experiences of underserved groups in each evaluation. Thoughtful model design is necessary not only for embedding health equity into every aspect of the models, but also for including data collection methods that can effectively track progress towards larger goals.
This review offered insight into the data challenges the Innovation Center is dealing with in measuring the progress towards its health equity goals. Despite the lack of sufficient data from the evaluation models, CMMI intends to use this information to fill gaps and improve data collection practices in order to design more equitable models. Our team looks forward to tracking CMMI’s commitment to advancing health equity through innovation.
[1] Bisma Ali Sayed et al., Assessing Equity to Drive Health Care Improvements: Learnings from the CMS Innovation Center, (Baltimore, MD: Centers for Medicare and Medicaid Services, 2023), 1-26, https://innovation.cms.gov/data-and-reports/2023/assessing-equity-hc-improv-wp
[2] “Innovation Center Strategy Refresh,” Centers for Medicare and Medicaid Services, 2021, https://innovation.cms.gov/strategic-direction-whitepaper
[3] Id.
[4] Bisma Ali Sayed et al., Assessing Equity to Drive Health Care Improvements, 1-26.
[5] Id.