Insurers wrestle with proposed marketplace rule

Insurers may soon be accountable for the health equity promises they make.

In recent years, insurance organizations and professional groups have committed to programs that address social determinants of health and promote diversity, equity and inclusion.

Now, such initiatives could become the baseline.

Government entities are considering making the National Committee for Quality Assurance’s Health Equity Accreditation mandatory for Medicaid and marketplace plans, which would require insurers administering them to comply with new standards meant to eliminate disparities in the communities they serve.

Some states have already moved to enact the requirement, but insurers have pushed back against a federal mandate for marketplace issuers. They cite costly operational changes, overly broad guidance and unproven effectiveness as reasons to hold off from making accreditation a federal requirement.

Consumer advocacy groups and public entities, meanwhile, say the mandatory accreditation process is necessary to revamp practices that perpetuate inequality within the healthcare industry.

“The NCQA standards are ambitious, and I think we need some ambition here,” said Christine Monahan, assistant research professor and faculty member at the Center on Health Insurance Reforms at Georgetown University. “Health disparities are a real problem, and we need to be pushing insurers to take more action to solve them.”

An updated accreditation

NCQA launched the Health Equity Accreditation in November 2021 as an expansion of its 12-year-old Distinction in Multicultural Healthcare program, which sought to standardize some data collection and language services among insurers and healthcare providers.

The updated curriculum aims to address health disparities by overhauling certain operations, data collection and network adequacy. It creates guidelines for collecting data on race, ethnicity, language, gender identity and sexual orientation with a goal of better understanding unequal outcomes among plan beneficiaries.

It also requires insurers to employ workers who demographically represent member communities and offer language services to communicate with members who don’t speak English. Additionally, it tasks insurers with measuring the cultural competence of their clinical networks.

“It’s looking to see if there is a match between membership in the plan and the practitioner network to be able to meet the needs of different members, and can (insurers) expand efforts being made to diversify provider networks,” Monahan said.

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According to a letter to the Centers for Medicare and Medicaid Services from the insurance trade group AHIP, data collected by insurers to identify health disparities is limited and unstandardized, especially regarding race and ethnicity information. The accreditation’s data collection requirements may therefore present a tangible opportunity to provide more equitable care, Monahan said.

“The biggest challenge to this health equity issue is just getting the right data,” said Anne Winter, senior managing director at the business advisory firm FTI Consulting. “It’s been imprecise, and so now the NCQA is (moving) to implement a screening requirement.”

Mississippi, Pennsylvania, Rhode Island, South Carolina, Tennessee and Wisconsin required the previous Multicultural Healthcare Distinction for Medicaid plans and will have the option to convert to the new version when that expires, an NCQA spokesperson said. Delaware and California have announced mandatory HEA accreditation for their Medicaid plans by 2024 and 2026, respectively. California will require the HEA accreditation for participation in its marketplace by 2026, as will Washington, D.C., which has yet to set a deadline.

The California Department of Health Care Services said it chose to mandate the accreditation to improve the quality of its plans and increase oversight of health outcomes.

“DHCS is looking at how to improve health equity across all populations, and believes NCQA’s health equity accreditation requirement will contribute to DHCS’ mission to reduce health disparities and achieve better health outcomes for all Medi-Cal beneficiaries,” a spokesperson said.

Insurers raise concerns

Amid the patchwork state-by-state implementations, CMS is weighing whether to mandate the accreditation for Affordable Care Act exchanges, which facilitate health insurance for approximately 14.5 million middle- to low-income individuals. The question was raised in planning documents for fiscal 2023, but a rule likely wouldn’t go into effect for several years to allow time for insurers to comply with the standards.

Although state governments would still determine Medicaid mandates, a federal rule would force major action throughout the country by insurance companies wanting to participate in the marketplace.

In response to the proposal, several insurers have pushed back. The National Association of Insurance Commissioners, Kaiser Permanente, Cigna, the Blue Cross Blue Shield Association and AHIP submitted public comments to CMS opposing a federal mandate of accreditation on marketplace plans. NAIC said any required equity accreditation should be up to each state regulator. Kaiser Permanente, which is subject to the mandate in California, said that achieving the accreditation should not be required, although it recommended marking plans that have done so with an identifier on consumer exchange platforms.

Cigna, which is working to comply with the standards to participate in Covered California, told CMS in a public comment that a federal mandate would be premature, noting the “significant operational work” it takes to meet the requirements.

The National Minority Quality Forum, a not-for-profit research and education organization, also objected to requiring qualified health plan issuers to obtain NCQA’s accreditation, saying the organization failed to seek input from “leaders in the health disparities movement who represent organized medicine.”

“They have not sought consensus from the communities who are to benefit (from) such an accreditation,” NMQF President and CEO Gary Puckrein wrote to CMS Administrator Chiquita Brooks-LaSure. “We encourage CMS to consider accreditors who have taken the time to ensure these underserved communities have a voice in the process that will determine the standards and measures that will determine the quality of care they are to receive.”

In June, NMQF announced a partnership with URAC, a separate accrediting organization, to develop its own set of health equity standards.

The NCQA program’s relative novelty poses a concern too. At less than a year old, insurers argue there is no evidence of its effectiveness, and say they should not have to implement requirements that aren’t guaranteed to work.

“We have concerns about requiring a particular distinction program, as such requirements can lead to ‘lock-in’ harms and are especially inappropriate when, as is the case where, there is no evidence that one program is more effective than others,” AHIP President and CEO Matt Eyles wrote in a letter to Brooks-LaSure.

In response to the concerns from insurers, a spokesperson for NCQA said the organization sought input from more than 30,000 people and organizations through a public comment period and email list in developing the new accreditation.

“We are certainly used to large organizations, including state governments, getting on board and putting out mandates for our programs,” the spokesperson said. “That’s what we’ve been doing for a long time.”

The NCQA will only begin checking applications for the new version of the accreditation in July and does not have precise measures on how the updated guidelines will work toward the goal of eliminating health disparities among patient populations. However, a review by the consulting firm Health Management Associates of the NCQA’s previous, less comprehensive Multicultural Healthcare Distinction found plans that underwent the process in California saw quality improvements and new health interventions.?

CMS said in a final rule published in May that it would consider the feedback as it explored options for advancing health equity in the exchanges.

On-the-ground implementation

Insurers on the forefront of the accreditation process speak to its operational requirements, especially where data collection is concerned, and the shifts in programming it can prompt.

CalOptima, an Orange County insurer that provides coverage through Medi-Cal and serves 150,000 dual-eligible members, is working toward earning the health equity accreditation and has hired an outside consultant to help with coming into alignment.

Marie Jeannis, executive director of quality and population health management, said one of the organization’s main focuses will be on its data collection efforts. CalOptima already collects data based on ethnicity, race, age, location and gender, which has helped it identify disparities across Orange County.

To expand on that, she said it will partner with community-based organizations to collect data on education, income, housing, food and the quality of water members are receiving.

“We may not be able to change the social determinants of health, but what we can do is move toward making sure that every single one of our members receives the support they need in a culturally appropriate environment (while) respecting their individual needs,” Jeannis said.

CalOptima is also expanding its internal coding to be more precise when collecting patient data. For example, the changes will allow it to recognize multiracial individuals or people who identify as gender nonconforming.

“It’s really about the individual and how they identify themselves, so we want to make sure we are obtaining that type of information at that detailed level to be able to address it,” Jeannis said.

Health Net, a Centene company that insures approximately 3 million people in California through Medi-Cal, Medicare and exchange plans, renewed its Multicultural Healthcare Distinction across all service offerings in 2021. It is building up its operations to obtain the HEA by the deadline.

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Laetitia Barrad, director of program accreditation at insurer Health Net, said the bulk of the work will lie with expanding its data collection infrastructure to include more categories, namely with regard to sexual orientation and gender identity. The need will be especially great in Health Net’s marketplace plans, where such efforts have historically been less robust.

The IT team is also determining how it will best store the data while maintaining privacy, she said.

Once collected, the data populates the insurer’s disparities dashboard, which shapes targeted health interventions. For example, Health Net offers a Black doula program to improve maternal health outcomes for women of color and offers breast cancer screening in Russian-speaking communities where uptake is low.

In addition, Barrad said the company must implement ways of tracking internal workforce diversity and hiring trends to ensure its employees reflect the communities it serves. That goes for its clinical networks too, where it faces some hurdles collecting workplace diversity data.

“We’ve noticed that providers aren’t as keen to provide that information, so it’s something that we are working on with our provider network team to try to get more information,” Barrad said.

It is also participating in a pilot program with NCQA for an enhanced version of the Health Equity Accreditation, which emphasizes community engagement through partnerships with local resources and not-for-profits.

“I think it’s very effective,” Barrad said of the overall accreditation process. “I think it requires a holistic view of your organization and your operations. You look at the social needs of individuals, social risks of communities and then look at how you are closing those gaps. And then how do you keep it going?”