Leveraging Equity Quality Measures to Reduce Disparities and Improve Outcomes
Inovalon Data Solutions experts collaborated with Humana to develop a new health equity composite quality measure. The equity measure definition and development process were presented in a session at America’s Health Insurance Plans (AHIP) 2022 Annual Meeting in Las Vegas, NV on June 28, 2022 by Kristin Russell, MD, Associate Vice President, Clinical Transformation, Humana and Christie Teigland, PhD, Vice President, Research Science and Advanced Analytics and moderated by Jim Clement, Vice President, Products and Services, Inovalon. The measure description and results were also published in an article in NEJM Catalyst Innovations in Care Delivery.1
Addressing Health Equity Across the Industry
The COVID-19 pandemic presented a wake-up call to the nation by highlighting its disproportionate impact on certain racial/ethnic groups, low-income individuals, and people with other social determinants of health (SDOH). An extensive body of research has documented how social and structural inequities lead to poor health outcomes.2,3,4 Addressing the SDOH that lead to health disparities has been associated with better access to and engagement in healthcare, as well as improved health outcomes and lower costs.5
It is clearly time for emphasized prioritization of health equity, and there are growing initiatives across the healthcare spectrum:
- The Centers for Medicare & Medicaid Services (CMS) is leading several initiatives including development of a Health Equity Summary Score for Medicare Advantage (MA) contracts. The measure may ultimately be incorporated into the MA Quality Star Rating program and Medicare Plan Finder.
- The Core Quality Measures Collaborative (CQMC)—a public-private partnership between AHIP, CMS, and the National Quality Forum (NQF)—has formed a health equity workgroup to identify disparity-sensitive measures and identify gaps in equity measures.
- The National Committee for Quality Assurance (NCQA) will require Healthcare Effectiveness Data and Information Set (HEDIS) measures to be stratified by race and other SDOH in 2022.
Analyzing Equity Quality Measures to Reduce Disparities, Improve Outcomes
Humana chose to focus on the domain of health behaviors and preventive care because improving member health at the upstream is critical. Among 29 candidate measures, eight were selected for inclusion in the health equity composite based on four criteria:
- The size of the disparity across racial/ethnic groups and dual eligibility for Medicaid status
- The clinical importance of the measure to overall health
- The prevalence within in the MA population (i.e., the proportion of patients for whom the measure applies or size of denominator)
- The ability of MA plans to impact the measure
The eight measures selected include three medication adherence measures, breast and colorectal cancer screenings, diabetes care-eye exam, influenza vaccination, and a measure of engagement in the healthcare system based on having at least one primary care visit within the past year. These measures were then summarized in a composite measure which averages the rates of performance within an MA plan across each of the measures (note that not every member was included in every measure).
The Inovalon research team developed benchmarks for the individual and composite Health Equity measures for MA members using Inovalon’s MORE2 Registry®, a statistically de-identified real-world database that is inclusive of medical and pharmacy claims primary sourced by over 140 health plans covering all major U.S. payers including Medicare Advantage (25% of market and nationally representative of all MA enrollees), commercial (42% of market), and managed Medicaid (69% of market). Inovalon also used the 100% Medicare Fee-for-Service (FFS) Parts A, B, and D claims data accessed through a CMS research data use agreement (DUA) to develop similar benchmarks for Medicare FFS. Humana generated the measure rates for their MA members.
Study Findings and Further Research
Overall, Medicare FFS and MA had similar rates of compliance on the health equity composite measure (64.9% and 65.1% respectively) while Humana’s members had higher rates (72.8%). However, MA had a narrower range of disparities when the measure was stratified by race/ethnicity and dual status (14 percentage point range versus 24 percentage point range in FFS). Thus, the similar overall rate of compliance was driven more by the demographic mix of MA versus FFS enrollees (e.g., MA has a higher proportion of members who are from a racial/ethnic minority group and a larger proportion of members who are dual eligible for Medicaid).
Blacks who were dual eligible for Medicaid enrolled in Medicare FFS had a 46.8% rate of compliance compared to White non-dual eligible beneficiaries who had a compliance rate of 70.6%. In MA, Black dual eligible beneficiaries also had the lowest rates of compliance on the health equity measure, but the rate (59.9%) was 13.1 percentage points higher than Black duals in FFS. Humana had a lower range of disparity of 9 percentage points across the stratified groups, but Black dual eligible members had the lowest overall rate of compliance on the Health Equity composite measure.
Humana plans to conduct further reliability and validity testing of the new Health Equity composite measure, and then use the measure to compare markets, contracts, and providers. Humana will provide actionable data to each of these stakeholders including individual and peer comparison scores and disaggregating the measure into the individual measure components to provide insight into where the largest disparities exist. Humana also plans to make the measure publicly available in the future.