CENTER FOR POLICY ANALYSIS AND RESEARCH CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity Health Equity
Oluwatosin Oyadiran, John R. Lewis Social Justice Fellow | October 2023
Op-Ed: CMS Innovation Models A Starting Point to Addressing Racial Bias in Healthcare This past year, I had the privilege of serving as a health fellow and legislative aide in the
Implicit bias has prevented Black Americans from benefiting from CMMI’s objective to enhance care quality.
United States House of Representatives and had insightful discussions with stakeholders about the Center for Medicare and Medicaid Innovation (aka CMS Innovation Center or “CMMI”). Through these conversations, it became evident to me that CMMI requires significant reforms, which must be approached with care to avoid exacerbating health disparities. Access is a critical driver for health equity; therefore, payment and service delivery models must prioritize cultural competence and ensure accountability. Policies and regulations that overlook racial disparities merely contribute to the problem. Thus, healthcare professionals, organizations, and legislators must enact active antiracist reforms and practices.
RACIAL DISPARITIES IN REIMBURSEMENT MODELS The CMS Innovation Center was established within the Center for Medicare and Medicaid Services (CMS) to pilot healthcare reimbursement models and ensure that active payment and service delivery models improve quality of care and lower healthcare costs. However, the non-inclusion of health equity at the core of these models has inadvertently promoted racial disparities. Further, implicit bias has prevented Black Americans from benefiting from CMMI’s objective to enhance care quality.
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Op-Ed: CMS Innovation Models—A Star ting Point for Addressing Racial Bias in Healthcare
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CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity
In 2021, CMMI identified three models that had more proclivity toward implicit bias—
According to a recent study by Lee et al. (2021), race plays a significant role in determining access to health insurance, with minorities who are in poor health being 68% less likely to be insured.
the Kidney Care Choices (KCC), the Comprehensive Care for Joint Replacement (CJR), and the Million Hearts Cardiovascular Risk Reduction models. • When adjusted for race, the KCC model erroneously elevated kidney function in Black patients, leading to delayed diagnoses, specialist referrals, and transplant listings despite a higher prevalence of chronic kidney disease among Black Americans (King, 2022; Tucker, 2021). The implications are unmistakable: Models may unintentionally introduce care delays and result in avoidable medical interventions and complications, diminishing the standard of care and erecting barriers to healthcare access. • The CJR payment model illustrates how a focus on cost-effectiveness without considering social drivers of health could result in harmful consequences for minority populations. The model disregarded social risk factors for joint replacement, excluding medically complex and dual-eligible patients needing more post-operative care. To fulfill the criteria for “quality thresholds” and the incentives for “lower costs” outlined in the model, patients who were more likely to incur greater costs (due to factors like social status or disease progression) were deliberately excluded. Consequently, Black patients showed a minor increase in the rate of elective joint replacement compared to Hispanic and white patients (Kim et al., 2021). • The quality of data and parameters used in models may also promote inequities. For example, the heart calculator in the Million Hearts Cardiovascular risk reduction model only considers Black, white and ‘other’ races, underestimating the risks for South Asians (King, 2022; Volgman et al., 2018). Such inaccuracies raise concerns about the accuracy of primary prevention of atherosclerotic cardiovascular disease for these populations.
A HEALTHCARE SYSTEM OF RACIAL BIAS Chronic diseases, such as hypertension, diabetes, and cardiovascular disease, are prevalent among Black Americans. Paradoxically, Black Americans encounter significant barriers to high-quality healthcare stemming from systemic racism, resulting in adverse socioeconomic conditions, delayed diagnoses, inadequate treatment, and avoidable complications, exacerbating health outcomes (Hill et al., 2023). About $42 billion is lost in productivity annually due to health inequities and could increase to $1 trillion annually by 2030 (Davis et al., 2022). According to a recent study by Lee et al. (2021), race plays a significant role in determining access to health insurance, with minorities who are in poor health being 68% less likely to be insured. Healthcare decision-making algorithms may also harbor racial prejudice. For instance, an algorithm using healthcare expenses to gauge health needs inaccurately inferred better health among Black Americans than white individuals
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Op-Ed: CMS Innovation Models—A Star ting Point for Addressing Racial Bias in Healthcare
cbcfinc.org
CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity
due to lower healthcare utilization. This led to Black Americans appearing in worse
Racial segregation has contributed to the emergence of Health Professional Shortage Areas (HPSAs) in marginalized communities, and when present, Black patients tend to receive care at hospitals with lower performance standards and are more likely to experience patient safety incidents.
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health than their white counterparts with similar risk scores (Obermeyer et al., 2019). Moreover, healthcare practitioners may possess implicit biases exacerbating these challenges and leading to misdiagnosis and substandard care. Racial segregation has contributed to the emergence of Health Professional Shortage Areas (HPSAs) in marginalized communities, and when present, Black patients tend to receive care at hospitals with lower performance standards and are more likely to experience patient safety incidents (Gangopadhyaya, 2021; Taylor, 2019). High-proportion Black hospitals also get lower reimbursements, have lower operating margins, and are more likely to be under-resourced and penalized by the Center for Medicare and Medicaid Services (Aggarwal et al., 2021; Himmelstein et al., 2023). Concerns about unequal care have permeated payment systems, ranging from the Diagnosis Related Group (DRG) to hospital Value-Based Purchasing (VBP) programs. Although industry specialists have welcomed CMS’s shift toward value-based care models, these models haven’t directly boosted equity; there has been no noticeable improvement in quality metrics, and costs have escalated (Kim et al., 2022).
Op-Ed: CMS Innovation Models—A Star ting Point for Addressing Racial Bias in Healthcare
cbcfinc.org
CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity
TRANSPARENCY AND ACCOUNTABILITY CMMI can enhance health equity in healthcare through a multifaceted approach. It could establish strategic partnerships with health equity experts, healthcare professionals, community stakeholders, and industry leaders. This collaboration would facilitate data-driven and inclusive model designs and encourage feedback on design proposals. CMMI could also enhance transparency by publicly sharing the rationale behind model implementation or non-implementation decisions. This could promote accountability and build trust in the decision-making process. To maintain fairness and equity within CMMI’s initiatives, it is essential to continuously assess active models for potential biases and openly disclose strategies to address current and future biases. Furthermore, CMMI could leverage technology and innovation to advance health equity, exploring ways to leverage cutting-edge solutions for improved healthcare access and outcomes.
LEGISLATIVE ACTIONS In enacting reforms, Congress must uphold CMMI’s autonomy and efficiency. Delving into CMMI’s intricate operations risks operational redundancies, implementation delays, and undue politicization, potentially worsening healthcare disparities. Instead, Congress should emphasize accountability for CMS and CMMI and primarily focus on health equity in model design and implementation. This approach further empowers CMMI to develop strategies for improving health outcomes among marginalized populations. To ensure the establishment of truly equitable and inclusive models benefiting all intersects of Black America, Congress must pass the John Lewis Equality in Medicare and Medicaid Treatment Act of 2023 (Sen. Booker, 2023). In addition to enshrining health equity in the core of payment models, this legislation instructs CMMI to create a Social Determinants of Health model centering on the social drivers of health for individuals with dual Medicare and Medicaid eligibility, behavioral health issues, and maternal mortality.
CONCLUSION As a trained doctor hoping to establish a future medical practice, I am quite passionate about health equity and enhancing healthcare accessibility. Lawmakers must pass laws that promote positive health outcomes for all races and prioritize health equity when making reforms to CMMI. CMMI must emphasize data transparency, uphold accountability, promote stakeholder engagement, and utilize technology and medical innovation to improve health equity.
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Op-Ed: CMS Innovation Models—A Star ting Point for Addressing Racial Bias in Healthcare
cbcfinc.org
CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity
REFERENCES 1. Aggarwal, R., Hammond, J. G., Joynt Maddox, K. E., Yeh, R. W., & Wadhera, R. K. (2021). Association Between the Proportion of Black Patients Cared for at Hospitals and Financial Penalties Under Value-Based Payment Programs. JAMA, 325(12), 1219–1221. https://doi.org/10.1001/jama.2021.0026 2. Davis, A., Batra, N., Dhar, A., & Bhatt, J. (2022, June 22). US health care can’t afford health inequities. Deloitte Insights. https://www2.deloitte.com/us/en/insights/industry/health-care/economic-cost-of-health-disparities.html 3. Gangopadhyaya, A. (2021, March). Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions. Urban Institute. https://www.rwjf.org/en/insights/our-research/2021/03/black-patients-aremore-likely-than-white-patients-to-be-in-hospitals-with-worse-patient-safety-conditions.html 4. Hill, L., Ndugga, N., & Artiga, S. (2023, March 15). Key Data on Health and Health Care by Race and Ethnicity | KFF. https://www.kff.org/racial-equity-and-health-policy/report/key-data-on-health-and-health-care-by-race-and-ethnicity/ 5. Himmelstein, G., Ceasar, J. N., & Himmelstein, K. E. (2023). Hospitals That Serve Many Black Patients Have Lower Revenues and Profits: Structural Racism in Hospital Financing. Journal of General Internal Medicine, 38(3), 586–591. https://doi.org/10.1007/s11606-022-07562-w 6. Kim, H., Mahmood, A., Hammarlund, N. E., & Chang, C. F. (2022). Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives. Frontiers in Public Health, 10. https://www.frontiersin.org/articles/10.3389/fpubh.2022.882715 7. Kim, H., Meath, T. H. A., Quiñones, A. R., McConnell, K. J., & Ibrahim, S. A. (2021). Association of Medicare Mandatory Bundled Payment Program with the Receipt of Elective Hip and Knee Replacement in White, Black, and Hispanic Beneficiaries. JAMA Network Open, 4(3), e211772. https://doi.org/10.1001/jamanetworkopen.2021.1772 8. King, R. (2022, July 6). CMMI finds implicit bias in 3 major payment models. Fierce Healthcare. https://www.fiercehealthcare.com/providers/cmmi-finds-implicit-bias-three-major-payment-models 9. Lee, D.-C., Liang, H., & Shi, L. (2021). The convergence of racial and income disparities in health insurance coverage in the United States. International Journal for Equity in Health, 20(1), 96. https://doi.org/10.1186/s12939-021-01436-z 10. Lopes, L., Muñana, C., & 2020. (2020, October 14). KFF/The Undefeated Survey on Race and Health—Main Findings. KFF. https://www.kff.org/report-section/kff-the-undefeated-survey-on-race-and-health-main-findings/ 11. Obermeyer, Z., Powers, B., Vogeli, C., & Mullainathan, S. (2019). Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), 447–453. https://doi.org/10.1126/science.aax2342 12. Sen. Booker, C. A. [D-N. (2023, April 26). Text - S.1296 - 118th Congress (2023-2024): John Lewis Equality in Medicare and Medicaid Treatment Act of 2023 (2023-04-26) [Legislation]. http://www.congress.gov/bill/118th-congress/senate-bill/1296/text 13. Taylor, J. (2019, December 19). Racism, Inequality, and Health Care for African Americans. The Century Foundation. https://tcf.org/content/report/racism-inequality-health-care-african-americans/ 14. Tucker, J. K. (2021, February 3). What’s behind racial disparities in kidney disease? Harvard Health. https://www.health.harvard.edu/blog/whats-behind-racial-disparities-in-kidney-disease-2021020321842 15. Volgman, A. S., Palaniappan, L. S., Aggarwal, N. T., Gupta, M., Khandelwal, A., Krishnan, A. V., Lichtman, J. H., Mehta, L. S., Patel, H. N., Shah, K. S., Shah, S. H., Watson, K. E., & null, null. (2018). Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement from the American Heart Association. Circulation, 138(1), e1–e34. https://doi.org/10.1161/CIR.0000000000000580 16. Wadhera, R. K. (2022, July 14). “REACHing” for Equity—Moving from Regressive toward Progressive Value-Based Payment | NEJM. https://www-nejm-org.libux.utmb.edu/doi/full/10.1056/NEJMp220474
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Op-Ed: CMS Innovation Models—A Star ting Point for Addressing Racial Bias in Healthcare
cbcfinc.org
CENTER FOR POLICY ANALYSIS AND RESEARCH
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Op-Ed: CMS Innovation Models—A Star ting Point for Addressing Racial Bias in Healthcare
cbcfinc.org