Good morning, everyone. Thank you for joining today's webinar. I'm Lindsay Kaysen with the Georgia Hospital Association, and we are very pleased to be your host for today. On behalf of GHA and in partnership with your state and hospital associations, we do welcome you to today's webinar, Pursuing Health Equity through Regulation and Reimbursement, presented by PYA. Before we begin with this morning's presentation, I will take just a moment to draw your attention to a few items of note. As you are joining in with us, you may have noticed that all participant lines are muted, and while those lines will remain muted throughout the duration of this morning's webinar, there are several ways that we do invite you to interact and engage with us today. So if you'll take just a moment and hover your mouse over the bottom of your Zoom window, there are several options available to you there. First, if at any point throughout the presentation you do experience any issues with audio or video, I encourage you to select that option to raise your hand, or you can always just type a comment in the chat, and I'll reach back out to you to help resolve any technical issues that you may be experiencing. Also, at the conclusion of this morning's presentation, there will be a time of Q&A. So again, at the bottom of your Zoom window, you should see that option there that says Q&A. You can go ahead and click on that and type in your questions as they arise throughout the presentation, and that way we can have them ready to address in the queue at the appropriate time. And a nice feature of the Q&A is that you can choose to submit those questions anonymously, so please don't be afraid to ask. And lastly, today's webinar is being recorded, and you all should receive an email tomorrow morning around this same time with a link to view that recording, and that link will be available for 60 days. If for some reason that email does go to your spam folder, you can always go back and use the same Zoom link to access the recording that you also used to join today's live session. And now, I would like to introduce our speakers to get us started this morning. Kathy Reap has more than three decades of leadership experience in the healthcare industry. Her hospital setting expertise is in compliance, financial advisory, reimbursement, and managed care. Kathy has helped with Medicare, Medicaid, workers' compensation, reimbursement, and many other complex programs and issues. She's a thought leader and provider educator, helping hospitals navigate regulations and the impact of change. Prior to joining PYA, Kathy served as Vice President of Financial Services with the Florida Hospital Association. She also held long-time hospital positions as well as roles working in patients' business, internal audit, systems management, diagnostic-related group management, and as a reimbursement director. And Marty Ross now serves as a trusted advisor to providers navigating the ever-expanding maze of healthcare regulations after a successful two-decade career as a healthcare transactional and regulatory attorney. Her deep understanding of new payment and delivery systems and public payer initiatives is an invaluable resource for providers seeking to strategically position their organizations for the future. Marty synthesizes complex regulatory schemes and explains in straightforward and practical terms their impact on providers. She provides employee compliance training programs as well as dynamic, customized educational and planning sessions for directors, executives, and managers. She received a Bachelor of Arts and a Juris Doctor from the University of Kansas. She's an active member of the American Health Law Association, the Kansas Association of Hospital Attorneys, and the Greater Kansas City Society of Healthcare Attorneys. Thank you so much, both of you, for being with us this morning, and we invite you to go ahead and get us started. Great. Thank you, Lindsay and Kathy. Note to file, we have got to shorten up those bios. Thank you for joining us today. We're excited to discuss health equity and how we see it now coming into reimbursement and regulation. It seems, especially since the beginning of this year, that the topic of health equity has been everywhere, and as we try and figure out where that trend is originating, we look first to two executive orders that President Biden issued on his first day in office concerning addressing racial equity in federal government programs, as well as in the context of the response to the pandemic. Shortly thereafter, the administration formed the HHS Office of Climate Change and Health Equity. In fact, you can see in just the press releases that CMS publishes on a regular basis. Since the beginning of last year, there have been 95 references to health equity in press releases. We compare that with only 22 references in the prior 15 years. The public focus on health equity really has its roots in two stories, of which you're very familiar, beginning with the unequal impact of COVID-19. We're seeing research now showing that racial minorities have been experiencing significantly higher incidence of infection, hospitalization, and death from COVID-19, and we know that the death rate for rural populations from COVID-19 is double the rate for their urban counterparts. And so this has truly highlighted issues that have been present in our health care system for years, but the inequity in distribution of resources, as well as the negative outcomes that these populations have experienced. Similarly, we're seeing this in unequal maternal health outcomes. Again, latest research is showing that Black and American Indian women are experiencing pregnancy-related mortality at rates two to three times higher than non-Hispanic white women. Those trends stay the same, even when you control for socioeconomic factors. And again, rural women are experiencing poorer maternal health outcomes as compared to their urban counterparts, including higher mortality rates. So it's an issue, again, that's capturing the public attention, that the system has inequities, and certainly there is the need to address these systematically. Marty, we've got another fly, and that is the overall cost of health care. There was a report that was published by Deloitte in June, and it was addressed in modern health care, basically talking about the excess cost of health care services due to health care disparities. The article indicated that currently, spending due to disparities is about $320 billion a year. The rate of increase in that is actually outpacing overall cost trends, and that by 2040, we would be expecting to see the cost of health care related to disparities alone impact the health care system by about $1 trillion. It would triple the size over the next 20 years. And just to give you a couple of examples, Marty gave you the example of COVID, the maternal health outcomes. Deloitte, in their report, says that racial disparities and diabetes management add $15.6 billion in spending per year, about 4.8% of the total cost of diabetes care. It goes on to say that disparities in asthma care cost about $56 billion a year, or nearly 4.3% of the overall spending for that disease per year. So we've got the issue of these factors now impacting our overall spending, to the point, and this is a horrible quote from this article, because from a health care perspective, we often are, I guess I want to say picked on, but the quote was, and this is from Deloitte Consulting, what you continue to see is a lack of concerted effort to go after that number collectively. Through cynical eyes, the message you can take away is that inequity and bias is profitable in certain circumstances. I don't think that's the message we want to deliver. A system with inequity is an inefficient system, and an inefficient system is expensive. And so not surprising that in April of this year, CMS published its framework for health equity, its strategic plan, over the next 10 years to identify and correct inequities in federal health care programs, specifically Medicare and Medicaid. The definition of health equity is front and center in this document, setting the goal that everyone should have a fair and just opportunity to obtain their optimal health regardless of the population or other factors that access care and health outcomes. And we'll strive to attain the highest level of health care for people, to misfocus our attention on avoidable inequities and eliminate health care and health disparities. So that's the very broad goal CMS has set forward, how it will evaluate its programming, its relationship with providers. And what we're going to focus here in specifically is how we now see that resonating in regulation and reimbursement. Let's start with some definition of related terms, because all of these have sort of found their way into our lexicon here, but just so we understand and appreciate the distinction between these different concepts. You're familiar with social determinants of health, or now we're hearing the term social drivers of health more frequently. These are neutral terms. These are simply identifying the conditions in the environment that impact our health outcomes. And generally, you'll see these grouped in five areas. They'll be economic stability, education, quality and access. You'll see health care access and quality, neighborhood and built environment, and social and community context. So there's sort of those broad what's going on in our world that impacts our health. Then we talk about social risk factors or health-related social needs. These are when we start adding a qualitative judgment that this is adverse social conditions that are associated with poor health. So this will be social isolation, housing instability, food insecurity. Research has been telling us for years that these factors impact health outcomes, oftentimes much more significantly than our access to health care services. You're also familiar with the term population health, which is focusing on the health outcomes of groups of individuals, not individual health outcomes, but populations and their health outcomes. And how do we think of those different populations, not just geographic? And what are the distributions of outcomes within those populations? And then finally, population health management, again, we're hearing more frequently now the term population health improvement, is a process of approaching improvements in health for defined populations. So you may be familiar in your own practice, population health focusing on our diabetic population, or focusing on our heart failure patients, but that also can be focusing on our patients who are members of racial minorities, or focusing on our populations within specific age groupings so that we can identify where are the drivers of outcomes and how can we impact those drivers. In its framework, CMS identified five priorities, so five lanes of work it will pursue over the next 10 years, beginning with expanding the collection, reporting, and analysis of standardized data. This is, if you want to address health equities, you have to find the health equities. You have to see where there are variations in outcomes and variations in access. So it is the ability to take our data and do a deeper dive to understand the source of those inequities. Secondly, is to assess the causes of disparities within CMS programs and address those inequities through policies and operation closing those gaps. Third, is to build provider capacity to reduce health and health care disparities, and that's really going to be our focus today. Fourth, is advancing language access, health literacy, and provision of culturally tailored services. And finally, we have increasing all forms of accessibility to health care services and coverage. So let's take a moment here and actually hear it from the horse's mouth. I'm a frequent listener to HFMA's Voices in Health Care podcast. This podcast back in May really caught my attention. It's an interview with Joe Pfeiffer, the president of HFMA, and Jonathan Bloom. He serves as the CMS principal deputy administrator. This is actually his second tour of duty through CMS as the number two. And so when Jonathan Bloom talks, we listen, since it provides such insight into what the agency is doing. And this was his discussion of health equity as a CMS priority going forward. Health equity is an important topic for many of our members and something we've been focusing on quite a bit, and I know it's a focus for CMS. What are CMS's goals when it comes to health equity? And then maybe to add on to that, what should hospitals do to help address this issue? We're just having this conversation today of kind of what this means for us to have a kind of health care equity agenda. First principle is, this is not a side project for CMS. This is not a team who is thinking about ways for us to promote better access to care. The way that we have really set the framework is, this is the fabric for the whole agency. So what the administrator has challenged CMS to do is every policy decision that we make, every operational decision that we make, from how we contract with vendors, for how we set reimbursement policy, for how we set coverage policy, needs to be brought through a lens of how will it shape health care delivery, how will it promote better access to care for all populations. So we really see this as a first and foremost policy framework, second management framework, and also a key operational framework for how we operate. When CMS makes decisions, when CMS reviews policy options, every decision that we make brings in criteria, will the policy, the contract that we're signing help promote better access to services, better access to coverage, closing gaps in care, for example. But that's how we set the agenda. We believe that there should be a similar framework for how every hospital, health plan, nursing home should operate going forward. And we're trying to set the example and set what we think is the right framework going forward for how CMS operates that we hope that others begin to mirror. But to us, this is a fabric of the agency, policy, operations, management, that we've really distilled throughout the agency, not as a kind of separate team, separate thought process. It is front and center for everything that we do. Health equity was an important topic for many, health equity, better access to care. Sorry about that. A little technical difficulty, but I don't think that leaves any room for question as to how health equity policy is going to impact CMS's relationship with providers going forward. So Kathy and I wanted to take a look at the status of this policy and how it's being reflected in the regulations and the reimbursement rules that have been handed down from CMS here in the last couple of years. So we spent a lot of time with a lot of pages in the Federal Register and identified for you eight specific topics of note on the idea that we have to see the trends in healthcare because we have to prepare ourselves moving forward of how the industry is moving. And we think these are very clear indications that the responsibilities will fall on providers to address the manner in which care is delivered to eliminate these inequities. So we'll start with the story back in 2017 with the Center for Medicare and Medicaid Innovations Accountable Health Communities Model. This program launched as a pilot project back in 2017 with 29 participants. And the goal was to test whether identifying and addressing poor health-related social needs would impact the cost, utilizations, and outcomes for this specific population. The participants utilized a 10-item health-related social needs screening tool developed specifically for this project that was intended to identify food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety in the population. Participants were responsible for screening Medicare and Medicaid beneficiaries. And then they were responsible for offering navigation services around community-based organization services for individuals that had more than one or more health-related social needs with two or more emergency room visits within the last 12 months. Certain of these 29 participants also then engaged in an additional work around coordination with key stakeholders from community resources. With the end of the AHC pilot project, we've seen some really detailed analyses of the outcomes. Most importantly is those individuals who had offered navigation services, three in four individuals accepted those services. They wanted the assistance to navigate these health-related social needs. It was less encouraging, the results, in terms of the ability to address and resolve those needs. We only saw that really with about 14% of those completed. The navigation process actually resolved the issue. But there were certainly issues with data collection. There were issues of people falling through the gaps. But we learned a lot through this particular pilot project on how to begin gathering the data and developing the relationships in the communities so that we can address these particular needs, these needs in individuals. We'll go also a little bit forward, moving now to 2019 and some changes that we saw to the Hospital Readmission Reduction Program. Now, this program dates back to 2013. It was one of the very first value-based programs that CMS launched. The intention was to incentivize hospitals to reduce readmissions by imposing a payment reduction on those hospitals that experienced higher than average readmission rates. There were a lot of complaints against this program early on because hospitals that served underserved populations claimed that they had higher readmission rates for factors beyond their control. So CMS in 2019 revamped the program and stratified hospitals into five groups. So rather than doing a comparison nationally, so those, you know, compare hospitals of all types, sizes, and capabilities nationally, we instead stratified these hospitals into five groups, and we focused on the percentage of dual eligible patients that they serve. So if you had a higher rate of dual eligibles, we use that as a proxy for an underserved population. Those with lower dual eligible rates, we assume, did not have the similar challenges. And so we stratify and then determine how to impose the penalties across those groupings. Some research that appeared in Health Affairs recently looked at the impact of Looks like she may have frozen. Kathy, did she freeze on your side as well? Yes, she did. So let me jump in. And I'm sure that Marty will reconnect momentarily. The article that was published in Health Affairs really looked at stratification. There she is. I won't go any further. Am I back? You are back. I apologize. I was just going to discuss the article, but you are here. Yeah. It simply found that we saw less penalties on these safety net hospitals when you did perform the stratification and thus appropriately reflecting the community that they were being served and the progress they were able to make in reducing readmissions. Well, let's fast forward to this year. In the 2023 proposed hospital inpatient prospective payment system rule, CMS raised the question, are there additional factors we should be looking at beyond just the number of dual eligibles served by a hospital to evaluate their performance on hospital readmission reduction program? And they suggested, for example, the area deprivation index or the social vulnerability index. And these are intended to look at factors beyond simply socioeconomic status to determine potential health inequities in the populations. CMS asked commenters to address the benefits and risks and potential unintended consequences of incorporating these other factors as we evaluate hospital performance across value-based purchasing programs. As you may know, obviously the comment period on the IPS rule has closed. The final rule is sitting with the Office of Management and Budget for its final budget impact review. We expect to see that rule published here in the next couple of weeks and we'll see what, if anything, CMS chooses to do in response to the comments received on this particular matter. Another area where we've seen health equity issues addressed has been in the post-acute space. The IMPACT Act of 2014 required CMS to begin collecting standardized data on patient assessment elements, or referred to as SPADEs, to better understand this population for purposes of then addressing through programmatic means ways to improve the quality of post-acute care. CMS is in response to this following a series of rulemaking and commentary from stakeholders, has added requirements for collecting social determinative health information as part of patient assessments performed by these post-acute providers. So at the time of admission, these providers will collect data on race, ethnicity, and language preference, and then upon discharge, they will also look at health literacy, social isolation, and transportation barriers and collect this information and report it appropriately back to CMS. The timing for the implementation of the SPADEs collection was announced in the Federal Year and Calendar Year Quality Payment Program rules, and you see here listed on the screen how those will be rolled in. We're also now understanding, again, from the framework, CMS's publication, the framework, that they're considering additional SPADEs to address gaps in health equity, so including additional screening requirements for those post-acute care providers. And Marty, I think one thing that's really important on that slide is for those with an LTCH or an inpatient rehab to recognize that you will be collecting this data beginning in October. And CMS is updating the survey tools, it's updating its educational programming for staff on these particular measures, so absolutely be aware of this additional information and the lessons you can learn here, because as we keep talking, you will find that these screening requirements are going to find their ways to other providers in the very near future. And the other thing I would mention is for a critical access hospital that has a distinct part rehab unit, they're going to be doing this as well, and they need to be thinking about that. Well, we started with our friends over at the Center for Medicare and Medicaid Innovation with the Accountable Health Communities model. Their more recent launch of the ACO REACH program certainly incorporates lessons learned from the Accountable Health Communities project, but also fits well into the framework CMS is pursuing with regard to health equity. ACO REACH was announced back in February. It's a replacement for the highly criticized direct contracting model, and it's set to launch next year. CMS announced on June 30 that it had received 271 completed applications, had accepted 128 of those into the program. They have not formally released the names of those participants pending execution of the participant agreements. This program has within it five requirements that relate to health equity. So ACOs that participate in ACO REACH will be obligated to submit a health equity plan. They will be subject to benchmark adjustments based on health equity. There are data collection requirements. There are certain benefit enhancements, and then the application that they submitted also included factors on health equity. Let's take a deeper dive on a few of those elements because we expect to see these replicated in other programs. The health equity plan requirement. So by early 2023, each ACO in the REACH program will be required to submit a plan on how they intend to identify and address underserved patients within their attributed populations and what initiatives they intend to pursue to measurably reduce disparities. Now, we're waiting still for CMS to release its template that will be utilized for purposes of developing this plan. It will be based on the CMS disparity impact statement, which we've previously been published. That includes detailed information on the underserved population. So understanding who's within your attributed beneficiary population, what those interventions are going to be, and then importantly, what the outcome measures will be utilized by the ACO to track performance over their period of participation. The health equity benchmark adjustment within the ACO REACH program is a very specific tool CMS is using to impact the behavior of ACOs in the REACH program. So CMS's analysis of its shared savings models has identified an issue with the use of historical benchmarks because there is historical underspending on underserved populations. And so if you're trying to beat your benchmark as an ACO and you're serving a population that has historically been underserved and thus the spending for that population has been lower, you find yourself in an impossible situation. You certainly want to improve access and services for that underserved population, but you're, by doing so, going to increase spending on that population. And so that runs counter to what you're trying to accomplish under a shared savings model. So CMS, for purposes of this program, is providing an upward benchmark adjustment to account for ACOs that serve underserved populations. And they're going to use a calculation that takes into consideration both the area deprivation index as well as the dual eligible status of beneficiaries. And for those ACOs that they put in the top 10 percentile, the 90th percentile, they're going to see a $30 bump in their benchmark, historical benchmark, intended to be a cushion for that ACO so that they can address that particular population. On the flip side, for those ACOs in the bottom half that are serving those populations that have historically had higher spending because they've had access to services, we're going to have a negative adjustment to their benchmark, a negative $6 PMPM, intended to sort of equalize the playing field among the ACO reach population. We'll come back again to this idea of benchmark adjustments as a tool for health equity incentives for those that are focused in on these alternative payment models. Regarding health equity data collection requirements, for their first year of participation in the ACO reach model, those ACOs that collect and submit data regarding demographic information among their attributed population, they will enjoy an upward adjustment to their quality score. One of the beauty of CMMI programs is they really can build it as they fly it. So for now, CMMI has not announced specific plans with regard to data collection in future years, 2024, 2025, going forward. In fact, they look for feedback from ACO participants regarding the type of information they should be collecting around social determinants of health, and then what the penalties or bonuses should be associated with the data collection within these programs. So they are going to be sort of our bleeding edge in terms of how organizations will be collecting and utilizing this data and what the incentives and disincentives will be around that. Going back to the framework for health equity, because remember this program was announced in February, the framework came out in April. In the framework, CMS said that all future CMMI models are going to include similar data collection requirements, have this similar focus on health equity. And in fact, we see that in a model just announced at the end of last month, CMMI's new enhancing oncology model. This is the follow-up to the original oncology care model. This is an opportunity for physician practices that furnish oncology services to participate in a combination practice incentive and shared savings model. Applications for participation in this program are due on September 30. CMS is still in the process of releasing information. Next week, there's a webinar CMS is sponsored on the payment mechanism within the enhancing oncology care model. But this CMMI model includes both program requirements and program enhancements, so STICs and incentives both. The program requirements include that these practices that participate will need to be completing screenings for health-related social needs of their population and also will be responsible for submitting a health equity plan, so how to better serve underserved patients within their geographic area. Program enhancements include the availability of additional payments to those practices offering enhanced services to their oncology patients. They'll receive a higher payment for their dual eligible beneficiaries. So if they're receiving a $70 PMPM payment to provide these enhanced care management services, navigation services, that amount will be upped by $30 for each dual eligible beneficiary for whom they provide those services. And then that enhancement will not be charged against their benchmark. So again, it's intended to sort of equalize the playing field based on the population served by those participating in this program. Also, CMMI promises to deliver to participants in the program data reports on expenditure and utilization patterns that are intended to assist participants in identifying and addressing inequities in their populations. One of the true advantages of participating in the CMMI programs is big access to claims data information. And CMS is taking this a step further and saying, we're going to analyze that claims data and provide youth participants with reports that actually show trends across different populations in terms of expenditures and utilization of services. Again, we have to understand the inequities to be able to address inequities, and certainly these would then inform health equity plans prepared by participants and submitted to CMS. Switching now to switching out of the CMMI world, it's sort of the experience we're going through with this cycle of proposed rules. You know, we are in sort of the middle of this cycle for the fiscal year and calendar year rules, payment rules for each provider type. And as Kathy and I have been reading those rules and trying to understand, again, the direction of CMS, we are finding in almost all of those proposed rules, a request for information from CMS of how to address disparities in quality of reporting programs. So, typically, we've just looked at data, you know, how have you performed on this measure, how have you performed on that measure, focused on the entirety of your patient population that you serve. And CMS is saying, we need to figure out a way to make that data more robust. So, how do we enhance our quality reporting programs so that we can see your data, how you performed on that particular measure across different populations? And so, how do you compare rural versus urban? How do you compare in racial minorities? And thus, we can truly understand where the opportunities are for improvement. And here, CMS is soliciting stakeholder feedback on how that can be accomplished, what their guiding principles should be, what should be the measures that they prioritize, what are the populations that should be prioritized, what social risk factors should we be looking deeper into, and where do we look at meaningful performance differences? So, this isn't just a matter of saying, how do you compare, you know, how do you compare serving your population against national percentiles? We want to look in a more robust manner into how you're improving your performance across different populations. Now, part of this, CMS has already started doing the work as it has developed its health equity scoring system. This is a stratification tool that CMS has developed, CMS's Office for Minority Health developed, and they've been utilizing as a proof of concept within their Medicare Advantage contracts. What this is intended to do is look at and compare how has a plan performed over time? How has it improved its performance across different populations over time? And then, how do we compare that to national benchmarks, both static as well as performance improvement over time? And so, they have developed this particular tool to provide that greater visibility into historic performance, and then also providing CMS with a vehicle for targeting incentives to achieve equity over time across particular populations. And CMS is presently evaluating use of this HEST tool for other providers, especially for hospitals and their inpatient and outpatient quality reporting programs. So, again, we're in this stage now with the IPPS proposal waiting for the publication of the final rule to see what, if anything, CMS introduces in response to the comments it received in the solicitation on quality reporting programs. Again, diving deeper into the IPPS proposed rule, specifically what CMS has proposed regarding the inpatient quality reporting program and the addition of two new measures specifically focused on health equity. The first of those measures concerns commitment to health equity. Remember, this, we're talking about the hospital quality reporting program. So, as you can see, as you're well familiar, there's a series of measures identified by CMS for which a hospital must collect and report its data. It is a pay-for-reporting program. Actually, it's a avoid-a-penalty-for-reporting program. So, it's not the scores on these measures that are determinative of payment. It's the fact that you've created the systems to collect and report the data. So, that's where CMS is using that program as a first vehicle in with specific obligations on hospitals around health equity. So, up to this point, everything we've talked about has sort of been optional in terms of if you choose to participate in that program, if you're collecting data here. But now we're getting into the realm of requirements. This first new IQR measure, commitment to health equity, is CMS's vehicle to determine what's the leadership's commitment to addressing health equity? And are they ready to move forward in closing the gap? And so, we're not looking at level of performance. We're simply measuring commitment to do something about this, that you take it as a serious, real issue within your community. It's not intended. This measure isn't intended to drill down on a particular element or data collection, but simply to create the processes to analyze your data across many factors so that you understand your performance in that more granular level. Here, you see the actual requirements for this measure. It is a one where it's a yes, no. It's simply you will go through and across each of these five domains respond yes, no to each of these statements, or true, false, actually, for each of these statements. And that, you get a point for each. That will give you the score on this domain. This, we're not messing around. CMS proposes that this measure be added to the set of IQR measures next year for calendar year 2023. That then would impact payment in 2025. As you know, in the IQR program, it's report the year of data, and then two years later, your completion of the reporting impacts your payment. And again, is this calendar, it, your slide says calendar year reporting, so this starts in January. Right, correct. Yeah. Not October. Right. Not October. The second measures, actually, it's two measures, but they're very closely related that CMS proposed to include in the IQR regards screening for health-related social needs. And this measure is, in fact, focuses in on the percentage of end patients 18 years or older at the time of admission for which you screened for these particular health-related social needs. So food insecurity, housing instability, and the like. It is up to the hospital to select the tool that they would utilize. And there are specific exclusions within the denominator. So if you have patients that refuse to be screened or who are unable to complete the screening tool during their admission, those are screened out. So we're focusing in on just those who would respond to the tool itself. And then the separate measure, again, closely related, are for those who screen positive, what intervention, if any, did the hospital pursue? So is there a referral for services? Is there some sort of care management service offered to those patients for each of the domains where there's a screen positive? Again, we're not wasting any time here. For calendar year 2023, this will be voluntary reporting, so to help you build your systems. And then it will be mandatory in 2024, meaning that will impact your payment in 2026. With that, I'm going to turn this over to Kathy to talk about Z codes. Okay. Thanks, Marty. And whether we're talking about Z codes or whether we're talking about the screening for HRSNs, recognize, as Marty said earlier, we are expecting an inpatient final rule any day. Should be out by the end of the month or the first week in August in order to be effective for October 1, even though some of these requirements would be effective January 1. But please recognize that it's going to be so important to look at the final rule and what it's expecting you to do. Read the response to comments. Stay tuned for our next webinar. One of the other proposals that is included within the inpatient proposed rule was a request for information, an RFI. We currently have a series of what we call Z codes. And these Z codes are used for capturing information such as your social, economic, environmental determinants. And just like you're going to code a complication, a comorbidity, a separate diagnosis on a claim, you're also going to be coding these Z codes. Reporting is currently voluntary. It is not a requirement that you report this on your claim. But CMS is saying should it be a requirement. So beware in terms of where this could take us. Essentially what you're going to have to do when we look at the Z codes, the conditions would be documented in the clinical record of the patient. But it doesn't have to be documented by the physician, but anyone who's actually a member of the care team. So this could be done by social work, anyone who is having an interaction with the patient. We are seeing a slight increase in the number of claims that are reporting Z codes, but nowhere near what we ultimately or what CMS ultimately would like to have. The next slide, Marty. And this just gives you an idea of the Z codes and what is out there. But recognize altogether we are really looking at more like 90 Z codes that could actually be identified on an individual patient. And the slide shows the top five Z codes out of those that have been reported. But recognize that for so many of these, we wind up having multiple Z codes on an individual patient. Obviously, if there is a housing and economic issue, there's probably going to be something related to food insecurity, related to transportation, et cetera. So we are not talking probably, I would say very, very rarely would we be talking a single code on a claim. If you go back to your current coding system, recognize that on a Medicare claim, you actually have the ability to report a principal diagnosis and 24 secondary diagnoses on an electronic claim, on the paper claim. You don't have as many, I think it's closer to 18 fields. So recognize that we are talking added coding to the system and perhaps increased administrative burden. But ultimately, this is information that we need to deal with and to assess in order to really know our patient population. The next couple of slides essentially come from CMS. And it walks through how you use the Z codes to capture the social determinants of health. And so just in the interest of time, we'll go on to the reporting of Z code slide. And just recognize that here are some of the issues that CMS has said related to the Z codes. They believe that reporting this, capturing this information is going to increase your quality improvement activities. It will better target your activities towards your patient population. Care coordination will be improved. And you're going to actually, it will provide further insight into existing health equities. In past proposed rules, CMS has questioned the impact of reporting these codes on resource use. They did actually propose at one point to have you report on homelessness. And to move that from a non-complication comorbidity into a complication comorbidity for an individual patient. But they did not finalize that particular proposal. So the focus is, should we be moving forward with reporting these codes? So CMS has recently asked a series of questions related to Z codes. Would the reporting of the codes improve the ability to recognize severity of illness, complexity, and utilization of resources? What protocol should be required to standardize the screening for social determinants? Has homelessness been underreported and why? And how do factors such as hospital size and type potentially impact the hospital's ability to develop standardized protocols? These are questions that are asked. Sometimes when you're reading a proposed rule, you kind of skim over the series of questions that are out there. But recognize somebody else is answering these questions. If the hospitals and the health care providers are not responding to these, someone is going to turn around and respond who is very focused on getting more information. And so recognize it's always important for you to comment about the impact on your own organization. Going on then to the another rule that was recently proposed, this would be the home health proposed rule. And what we're trying to get, the point we're going to get across, they raised it in the inpatient rule. They've raised it now in the home health proposed rule that just came out in June. But essentially what they're looking for here is to, again, soliciting comments, soliciting feedback. They aren't proposing anything. They're just saying, tell me what you think about. So on the quality reporting program for home health, essentially they are looking at should additional composite measure points be awarded into those various domains for a home health agency. Similar to what Marty talked about earlier in terms of awarding points for reporting this information. And the domains that they are looking at would be equity as a key organizational priority. Is there a commitment to equity within your organization? Are you doing diversity, equity and inclusion training for the board and staff? And what types of activities, are you providing activities related to organizational inclusion? Again, you're not going into detail. You're just saying we're doing this. Yes, yes, yes. And you would be awarded a point or points. But this is a proposal, say, should we go forward with this? And then in the value-based purchasing program for home care, they are also soliciting comments about making some adjustments similar to what was done with the inpatient readmissions reduction program, but to make adjustments to the value-based purchasing program for home care related to the populations that are served by that particular agency. Should we look at dual eligibility? Should we look at other social determinants of health to modify the impact on value-based purchasing? Is it harder to improve value when you're dealing with a dual eligible population? So, Marty? I checked, Kathy. Comments are due on the home health proposed rule on August 16th. So that date is coming quickly. Let's talk about another proposed rule, this one that came out on July 7th. It is the 2023 Medicare Physician Fee Schedule proposed rule. And there are a series of components of this proposed rule that, again, address this theme of equity. Most significantly are the changes that CMS proposes to the Medicare Shared Savings Program, the MSSP, which is certainly far and away the largest and most successful of CMS's value-based programs. So, when you read the proposed rule, there are several pages that discuss the value of alternative payment models in promoting a health equity agenda. And that ties in with the report that Kathy was discussing at the beginning from Deloitte is that we know if a system has inequities in it, it has inefficiencies and thus increases costs. And so CMS is drilling down on the participation in these alternative payment models that create incentives for providers to address these inequities and improve care for underserved populations. So CMS, in evaluating the MSSP, wanted to find those opportunities to enhance the rewards to providers that arise out of these types of alternative payment models. Importantly, in the MSSP, there is a new advanced investment payment option. So for ACOs coming into the program, smaller ACOs coming into the program, they will have an opportunity to receive an upfront payment, an advance on their future shared savings that they can utilize for purposes of developing infrastructure and providing services to underserved populations. There's the restrictions on the use of those funds. It's a quarter of a million dollars out of the gate. And then there are eight quarterly payments that are adjusted based on the nature of the population that you serve as an ACO. And the intention here is to provide the upfront funds that will incentivize more providers to organize into ACOs and to move into the program. Additionally, CMS is including new adjustments to the quality scores and how those are calculated for ACOs and affording those, again, ACOs that serve underserved populations will see a positive adjustment to their quality scores. That's an opportunity to increase the amount they receive in shared savings for those ACOs that provide underserved populations. Keep in mind that CMS, in its CMMI strategic reset, established a goal of having 100% of all traditional Medicare beneficiaries in an accountable care arrangement by 2030. So certainly revamping the MSSP, providing these opportunities to advance health equity is part of that strategy, but likely to see more of this coming in the next several years through other programs CMS is promoting. Within the, part of the Medicare shared, I'm sorry, part of the fee schedule each year are updates to the quality payment program, sometimes referred to as MIPS. And again, CMS is introducing health equity into the QPP. It has identified that health equity measures going forward will be included in the list of high priority measures for purposes of the calculation of a provider's quality score. CMS also has solicited comment on whether to include new quality measures that are focused on screening for social health needs, as well as changing the CAHPS survey that is included within the MIPS program to include equity-related questions. Also CMS is proposing new improvement activities to be added to the list, focusing on the creation and implementation of a plan to improve care for LGBTQ plus patients, as well as the creation and implementation of language access plans. So here we see CMS saying we can create an incentive through MIPS and the points for improvement activities, focusing in on specific populations, on specific needs that relate to health equity. Finally, in the MSSP, there is a request for information on underutilization of high value services. So CMS poses the question, why aren't we seeing the high rates of utilization we would like to see on what we consider high value services, such as preventative care services, such as care management or remote patient monitoring? What's the disconnect in the system that providers are not pursuing these opportunities? Because we believe these can truly move the needle when it comes to health equity issues. And so they are seeking comments, again, from stakeholders on what are the other high value services? What else should we be considering in terms of services that move the needle on health equity? Help us understand the obstacles that underserved populations face in accessing these services. Help us understand the obstacles to providers delivering these services across broader populations. And we want to focus in on policy, payment, and procedural changes. Don't worry, I'm on page five of my comments so far in response to this RFI, and certainly encourage you to take a look into the proposed rule, review this RFI, and identify those opportunities for you to comment. Yes, it's specific to the Medicare Physician Fee Schedule, but certainly CMS would consider comments applicable to other provider types as well in its response here. So with that... And Marty, before we go on, I think we've got the same thing coming through in the outpatient rule that was also proposed and asking for comments. Going back to what I said at the very beginning about the article about the cost of healthcare disparities, we don't want anyone saying we're biased in healthcare. And therefore we have to comment and talk about what we need in order to move forward with providing these services where they're needed. So Lindsay, we are at the top of the hour. We're certainly willing to stick around and answer questions if folks have specific questions. Again, we can also respond via email. Kathy's and my contact information is included in the PowerPoint that folks will receive if they want to communicate that way. So I'll turn it back over to you. Absolutely. We did just have one question come in that we might reference now, and then if anybody needs to hop off, you can certainly do that. And then you go back and listen to the recording if that is an option for you. This question just asks if collecting race and how patients identify for race and ethnicity is a barrier for good data. And this person wanted to hear if others potentially have issues as well as CMS. Is data for health and equity built from zip codes, census, or from claims data? First regard, the collection of data on race, certainly you're dependent on the expectation in these programs is that you're dependent on information furnished by the patient. And in the formal report on the accountable health communities program, they noted that it's certainly a challenge to get reliable information and people's unwillingness to share data and the like. But I think these are just a series of questions we're going to have to resolve as we move forward. How can we get patients comfortable to share this information, make sure they understand that that information will be confidential, certainly subject to all the protections that provide any other information that's shared with providers as well. Kathy, anything to add? No, I was going on to the second part of the question. And I'm going to go back to the data for health and equity built from zip code, census, claims data. Yes, yes, yes. And actual enrollment in the Medicare program and the information that is reported at that time in terms of race, gender, et cetera. That information, there is some information that when you actually enroll is reported. Information like your dual eligibility, that is something that they have actually from the Medicare enrollment information. On that line, one other comment from the AHC report was the success of participants in educating patients why they were collecting the information and having those communications with patients saying, we're asking for this data so that we can improve how we deliver care. And they noted that was a crucial conversation and really was helping those organizations do a better job collecting data. And I think that, and I applaud GHA and those other states that are participating today because this is a message that has to be taken down throughout your organizations because we really do have to start talking about these issues and then educating staff in terms of how to appropriately ask the information. Sometimes it's very tough. It's not necessarily something that you're going to be having the registrar at admissions ask some of this information, but it actually increases the role of the case manager or the case worker, the social worker who's going in and talking to the patient more about their overall situation. I just refer you to that commitment to health equity measure that proposed for inclusion in the hospital IQR and look at those domains because it really is a roadmap for how your organization should begin tackling these issues because it's the right thing to do because it's going to better propel you for future value-based care because there's going to be additional regulations coming down creating these expectations. Perfect. Thank you both so much. That is the last question that I see at this time, but as Marty mentioned, if you do think of additional questions after we conclude today, you can always reach out to us at education at gha.org. We'll be happy to get those questions over to Kathy and Marty, or I believe it's the second slide that was presented today has their direct content information, and I'm sure they'd be happy to work with you to get an answer as well. And so you will all receive an email from us tomorrow morning, again, with a link to the full recording of today's session, and we will also include a link to the slides in that email as well. Just note that that will come from a slightly different email address. It actually comes from educationnoreplyatzoom.us, so it is possible that it could get caught up in your spam folder, so if you don't see that tomorrow morning in your inbox, just check your spam folder, and if not, you can always go back and use the same Zoom link to access the recording that you also used to join this morning's live presentation. And with that, we can go ahead and conclude this presentation. Thank you so much to Marty and Kathy for your time and the wonderful information that you presented to us today, and we look forward to having you with us for future sessions, and thank you so much to all of you for attending today, and again, if we can help answer any questions, you can always reach out to us at education at gha.org. Thank you so much. Have a wonderful day.

health equity

regulation

reimbursement

CMS

Accountable Health Communities Model

Hospital Readmission Reduction Program

ACO REACH

Medicare Shared Savings Program

social determinants of health

Z codes