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AHLA's Speaking of Health Law
Top Ten 2023: Implications of the CMS Framework for Health Equity
Based on AHLA’s annual Health Law Connections article, this special series brings together thought leaders from across the health law field to discuss the top ten issues of 2023. In the fourth episode, Deborah Biggs, Principal, PYA, speaks with Dawn Hunter, Director, Southeastern Region Office, Network for Public Health Law, about the recent CMS Framework for Health Equity 2022-2032 and the Executive Order to which it is responsive. They discuss the priorities in the Framework, some examples of guidance for providers and institutions, and how organizations can work toward health equity. Sponsored by PYA.
Watch the conversation here.
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A H L A is pleased to present the special series highlighting the top 10 health law issues of 2023, where we bring together thought leaders from across the health law field to discuss the major trends and developments of the year. Support for A H L A in this series is provided by P Y A, which helps clients find value in the complex challenges related to mergers and acquisitions, clinical integrations, regulatory compliance, business valuations, and fair market value assessments, and tax and assurance. For more information, visit pya pc.com.
Speaker 2:Welcome to ALA's top 10 20 23 podcast. We will be talking about the implications of the CM S framework for health equity. I am Deborah Biggs and a principal with p y a, the academic medicine practice, and I am with Dawn. Hunter. Dawn, would you like to introduce yourself?
Speaker 3:Yeah, Debra, great to be here with you today. I am Dawn Hunter. I am the director of the southeastern region of the Network for Public Health Law. We are an organization that provides leadership on the use of law and policy to protect, promote, and improve health and health equity. Um, and we do that through nonpartisan, legal, technical assistance and resources to a wide variety of partners, um, throughout health and care and public health sectors.
Speaker 2:Wonderful. Well, thank you for joining us today, and thank you for your article that you've written. Can you tell us about the recent c m s framework for health equity 2023 and the executive order? This is in response to?
Speaker 3:Yes. So this current framework was issued in April of 2022, and it's actually an update to a 2015 plan, the c m s equity plan for improving quality in Medicare, and it's responsive to executive order 1 39 85, which was advancing racial equity and support for underserved communities through the federal government. And essentially what this executive order is about is directing federal agencies to do a number of things to help advance racial equity. Um, and one of those things is to develop equity action plans. And so, uh, this framework falls into that category. One important thing to note about the executive order is that it's not just about racial equity, it also is, uh, references intersectional identities. So these are things like, uh, gender identity, sexual orientation, um, ability, uh, and these are all things that are factors in how to, how to address equity broadly. Uh, another important thing to mention about the context of this framework is so that executive order was issued in January of 2021, and 2020 as a reminder, we had covid, right? We had significant disparities for black and indigenous people, um, and Hispanic or Latino people, um, due to Covid. And at the same time, we also had the murder of George Floyd and other victims of police violence. And we saw the racial justice movement of the summer of 2020 really give rise to declarations of racism as a public health crisis. So when this executive order was issued, we had over 200 jurisdictions that had issued declarations and a real momentum behind trying to both find ways to identify, um, strategies to address covid disparities, but then also to broadly address longstanding racial and ethnic care health disparities.
Speaker 2:Yeah, that's, that's something else here. Um, can you give us an idea of the priorities in the framework and perhaps suggest some examples for guidance for providers or institutions how to address these?
Speaker 3:Yeah. There are five priority areas, and if you're familiar with the 2015 plan, they're very similar. Uh, they're the same priorities. Essentially, that plan has six and these ones have been updated and they're a little bit more expansive than in the past. So those five priorities are expand the collection, reporting, and analysis of standardized data, assess the causes of disparities within c m s programs, and address inequities in policies and operations to close those gaps, build the capacity of healthcare organizations and the workforce to reduce health and healthcare disparities, advanced language access, health literacy, and the provision of culturally tailored services and increase all forms of accessibility to healthcare services and coverage. And Debra, I will talk about too, that, um, all of them are important, but I'm gonna talk about number one, which was the data, the data priority, and mentioned a couple of things here. So one is at the network for public health law, we actually have a team of attorneys who specialize in public health data sharing, and we just issued a framework called Pathways to, yes, it's a guidance toolkit for, um, for how to p share data on health and health related social needs, which is part of what this new framework is trying to promote and support. Um, this also is important in the context of legislative trends that we've seen over the last couple of years at the state level to e establish requirements for real data R E L D data. So race, ethnicity, and language and disability status. Um, and so one important consideration for this particular priority is how, um, federal and state requirements, um, integrate with each other and how those requirements can be implemented. Another I important consideration in this framework is that there's a real emphasis on social determinants of health data. So these are things about housing, perhaps education, employment status, um, and other social risk factors. And one important consideration is what do you do with this information? So when we think about implementation here, we're thinking about ensuring that as a hospital or health or health system, um, that you have systems of connection available for patients and that this is in particular, a great spot to leverage community health workers, peer navigators and other health pa peer professionals that can connect people to services. Do you have an existing medical legal partnership? These are all ways to help make sure that there is a system of care that's integrated so that patients are getting treated holistically. Um, the second one I wanna mention is actually number three, which is building the capacity of healthcare organizations in the workforce. So if you go through the plan, you'll actually see a few things like accountable health communities model implementation and minority research grants. Um, you'll also see a real effort to support behavioral health service parody with physical, uh, health services. One important thing I wanna note here though is, um, establishing affinity groups and learning networks. So c m s is doing this. One thing to consider is how your organization could do this. Do you have affinity groups? Do you have a peer learning network? Um, are you making sure there are connections, um, for employees in the workforce? And are you supporting people to participate in these, um, work groups and affinity groups and learning communities? A couple of examples of what those are, at least on the CMS end of things, is there's a tribal technical advisory group. There's also the Medicaid director's letters, and there are other ways that, so CMS is providing support. Uh, but I will say, check out the report. It's great. It has lots of great examples of what C M S is doing and the c m s resources that are available to provide support. The last thing I'll mention, um, on this particular question is that this particular framework is actually expanded to all C M S programs. So the 2015 plan was, um, just for Medicare. So this now applies to Medicaid, uh, chip programs and the state health insur, uh, the insurance marketplaces. So it's broader in scope and it's also, um, broader in applicability.
Speaker 2:Thank you. That's all really very helpful information. A couple of questions. I have those, while we're talking about, um, responding to the executive order and responding to C M S'S framework, what are some reasons that are helpful for an organization to consider about the benefits of health equity in general? Not necessarily just because of the, the order?
Speaker 3:Yeah. So hopefully health equity isn't new to your organization. If you're listening to this and it is, that's okay, but hopefully you've been thinking about how to integrate strategies to improve health outcomes for the population that you serve. So the first thing I would say is this framework and the effort to achieve health equity should be tied to your mission and vision as an organization. What is that? And what is your organizational plan? Do you have a strategic plan that incorporates health and racial equity and, uh, strategies to help achieve those? The other thing I say, like at a broad level on the public health side of things, because that's my world, is that focusing on health equity is a, a way to help improve the health of individuals and communities. So we all know the benefits of having healthy people, but we also know from research that, um, better access to healthcare and better health outcomes lead to greater economic stability, better long-term educational achievement, all kinds of better social and economic outcomes, right, as well in addition to just being healthy. But there are organizational benefits too. So these are things like investing proactively in health, um, can, is actually less costly to you than reactively responding to health needs. So one good example in the healthcare sector is for people experiencing homelessness or housing instability. It costs a lot to address all the health related social needs associated with housing instability, but proactively investing in housing as a, as a solution, as part of the healthcare solution, um, reduced cost to the organization and also helps to create, um, the conditions for people to be healthier. And this is for example, where you might see hospitals engaged, um, as anchor institutions and working at partnership with, um, housing organizations and local governments to establish housing first programs, um, as just one example.
Speaker 2:These are all, again, very helpful. You know, one of the, the issues that we've found in the past is that when you get into the social determinants of health and you have a provider that's working with their patient on that, they don't know how to address the issues when they find out that maybe there's food insecurity or their financial issues. And how would you suggest either training providers or resources that might be available to provider, provider organizations that can help'em at the point of care with a patient to get the patient that needs, you know, the, the access to the resources that they need?
Speaker 3:Yeah, the first thing that comes to mind, and you said it is training. And so one way to do that in a, in a way that addresses it at a systems level is through continuing education repri, uh, requirements from licensing boards. So this is establishing requirements that are part of your licensure renewal, perhaps even to obtain your licensure in the first place. Um, and that is a broad set of training that could address things like implicit bias, what are the social determinants of health and health equity, and really making sure providers have an understanding of what that, um, looks like in a healthcare setting. Uh, but then also providing even opportunities to engage around these topics in the workplace setting outside of any kind of mandates for, for training. So these might be instituting lunch and learns, or, um, incorporating it into grand rounds or things that, um, can really build on education and practice. The other thing is, um, that even if an organization is really not positioned to do that, or those requirements aren't in place, there are so many partners that health systems can work with who do provide these trainings, who are well-versed in these issues. And this is where I would say this is where the opportunity for healthcare and public health in particular have a real key opportunity to integrate, um, because health departments can help to offer these trainings or connect to partners who offer these kinds of trainings, um, but also can help connect people to services importantly. So, you know, these are folks who know what services are available in the communities for the populations that are most underserved and and in greatest need. So, you know, I would say training and partnerships are two key ways to address that gap.
Speaker 2:Thank you again for that. So this feels to me like it that even c m s recognizes that this needs to be part of a longer process by creating the framework over a 10 year period suggests that they understand that this is gonna take an organization a while to address and this is a path that they need to get on in terms of, uh, steps to take. I wonder if maybe you could speak a little bit to the process. You've already given us a couple of ideas related to training and partnerships within the community that can help address these issues, but what are some of the other strategies we might suggest?
Speaker 3:Yeah, well first I wanna say I appreciate you pointing out like this is not a new issue and y the 2015 framework helps to illustrate that. But realistically, looking back at the history of healthcare in this country, we're talking, you know, hundreds of years of history, but in particular in the time period from the sixties to today, you know, real efforts to address, um, how to leverage lawn policy to ensure access to care, and to start to reduce some of the disparities that we see. So I would say being really strategic about how we can leverage existing lawn policy to make differences in outcomes. Um, one thing that we, everyone can do is continually review policies and programs through a health and racial equity lens. What does that mean? That means that you have some regular cycle of review for policies, organizational policies in particular for your programs that you use a tool. And these, this is, doesn't have to be complicated. There are tools that are five questions that are really getting at, um, how well you've assessed the needs of the community that you serve and integrated the voices of impacted people in the population that you serve in making policy and programming decisions. So one is ensuring that you have that process in place. Um, two is considering how you can incorporate the c m s framework for health equity into existing operations. So you don't have to start from scratch and you don't have to reinvent the wheel. You probably already have positions, programs, task forces, or something that are dedicated to patient quality, uh, quality of care, um, to education. So how do you leverage those existing, that existing infrastructure that you have to implement this framework? That's something that you can do. Um, the one thing I like to point out with public health always is that change takes time, especially when we're talking about population health outcomes. It could be three years to five years before we may see significant moving of the needle on things. So one thing that's absolutely critical that is really just about relationships, um, and just understanding that how we show up to the work as people, members of the workforce is spending time to get organizational and workforce buy-in. Everyone is not going to be on board. Um, you're going to experience challenges with implementation. So one of the things you can do is just lay the groundwork for people to have an understanding of why you wanna adopt this framework, what kind of benefits it will bring to you, to your organization, to providers, to the community that you serve. Really being intentional about that process and spending time on it is key to longer term success. And then putting policies in place to support that and implement that framework. I would say with accountability mechanisms. So these might be things like deliverables, a regular report that's required, um, consistent committee meetings that are on some kind of regular schedule, ways to ensure that there is, um, a way to monitor progress and report back on what's being accomplished and where there's opportunity to make change. And so that would also be, again, a way that you can implement this into existing operations is considering an evaluation framework.
Speaker 2:So the first, the first, uh, priority from c m s is expanding that collection, reporting analysis of your standardized data. So it sounds like the first order of business has really gotta be for an organization to develop that standardized data, understand where they're gonna get that information, and being able to take a, a clearly look at their own organization and get that baseline data so that they can see and track their progress as they move along what, and, and get those reports into a standardized fashion so that their leadership and everyone with their organization is looking to see that progress. Uh, what resistance would you expect to see? You mentioned a little bit about the workforce, but are there other areas or, or ways in which you could help an organization address that?
Speaker 3:Yeah, I mean, one of the biggest areas I think that's a challenge is probably is in public health too, right? Is political will. And so this might be the, there might be leadership resistance to making these kinds of changes. You might have significant workforce resistance to making these changes and you may wanna implement changes that the people that you serve might not be totally on board with or understand. And so I think that ties back into my recommendation that you take time to establish buy-in, um, within your organization, but I think that it also extends to the community. So you have to really be educating and engaging with your partners in the community and the people you serve so they really understand the value of taking this approach or implementing this approach. I would say there are also just operational considerations. So data's a good example. Do you have the systems to collect the data that you need? You know, and are you meeting any kind of state or federal requirements? So somebody's going to have to review those and make sure that you can be compliant with them, but then you also have to have the technology to support that effort. And so that might have a cost associated with it. Um, and that might require changes to existing systems or upgrades to existing systems. So you need to be prepared for those kinds of, um, issues to come up as you consider implementing the framework.
Speaker 2:Fantastic. Thank you, Dawn. Really appreciate your time today.
Speaker 3:Thank you, Deborah. I'm so glad we got to have this conversation.
Speaker 1:Thank you for listening. If you enjoyed this episode, be sure to subscribe to a H L A speaking of health law wherever you get your podcasts. To learn more about a H L A and the educational resources available to the health law community, visit American health law.org.