Hospital Regulatory Requirements to Address Health Equity

While the healthcare industry’s primary focus is the treatment of injury or illness, achieving health equity is much more complicated. Effective action requires community coalitions with employers, public health agencies, community, faith-based organizations, and elected officials.  Fundamental to success is an understanding of the underlying attributes of a population group, called the Social Determinants of Health (SDOH).

Since 2010, not-for-profit hospitals have been required by the Affordable Care Act to conduct a community health needs assessment (CHNA) once every three years and develop strategies to meet needs identified by the CHNA. 

The Center for Disease Control (CDC) defines a community health needs assessment as: 

• the process of community engagement

• collection, analysis, and interpretation of data on health outcomes and health determinants

• identification of health disparities

• identification of resources that can be used to address priority needs

The Joint Commission (TJC) published new health equity requirements effective January 1, 2023, for ambulatory health care, behavioral health care and human services, critical access hospitals, and hospital accreditation programs.  The TJC requires such organizations to:

1. Designate an individual(s) to lead activities to reduce health care disparities for the organization’s patients

2. Assess the patient’s health-related social needs and provide information about community resources and support services

3. Identify health care disparities in their patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients

4. Act when the organization does not achieve or sustain the goal(s) in its action plan to reduce health care disparities

5. Monitor effectiveness of its action plan to reduce health care disparities in its patient population

6. Inform key stakeholders, at least annually, including leaders, licensed practitioners, and staff, about organizational progress to reduce identified health care disparities

Achieving TJC requirements requires actionable data in support of a structured process for identifying health disparities, and developing programs to address them, as well as measuring results to inform future initiatives. Other accrediting organizations are adopting similar initiatives.

The Centers for Medicare & Medicaid Services (CMS) has published a ten-year Framework for Health Equity Priorities. In a specific rule tied to hospital reimbursement, CMS has added three health equity focused measures to the Hospital Inpatient Quality Reporting (IQR) Program. For acute care hospitals paid under the Inpatient Prospective Payment System (IPPS) that successfully participate in the IQR Program and are meaningful electronic health record users, this final rule will result in an increase in payment rates of 4.3%. 

The first new IQR measure assesses a hospital’s commitment to establishing a culture of equity and delivering more equitable health care by capturing activities across five key domains, including strategic planning, data collection, data analysis, quality improvement, and leadership engagement. This Hospital Commitment to Health Equity measure begins with the 2023 reporting period.

The second and third measures address screening and identification of patients’ health-related social needs. The second measure is the percent of inpatients screened for these five SDOH needs, and the third measure is the percent of patients screened who had an SDOH risk factor identified.

CMS has designated five social needs for screening and identification: food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. CMS notes in their final rule that certain ICD10 Z codes (Z55 - Z65 - Persons with potential health hazards related to socioeconomic and psychosocial circumstances) are not well utilized by hospitals for a variety of reasons to identify SDOH in their patients. However, CMS chose not to require use of these codes for SDOH measurement but is requiring more detailed screening measures.

Screening for Social Drivers of Health (measure 2) and Screen Positive Rate for Social Drivers of Health (measure 3) begin with voluntary reporting in 2023 with mandatory reporting required in 2024.

In addition, CMS has created a new designation to identify “Birthing-Friendly” hospitals and additional quality measure reporting to drive improvements in maternal health outcomes.

This regulatory spotlight on health equity is well intentioned. However, the ultimate question is: will identifying social determinants of health and referrals to services reduce health disparities?