The tax and external reviews from the Joint Commission create buy-in and industry accountability, while the annual incentive payments reward organizations that successfully invest in health equity, said Dr. Frank Osborn, interim chief medical officer for Tufts Medicine Integrated Network, a value-based physician network affiliated with Boston-based Tufts Medicine.
"The challenge is being able to execute on a fairly big change in a time and place where every dollar is critical. It's a challenge when people are just trying to make sure the ship is still afloat," Osborn said. "MassHealth has really given us an opportunity and a glide path to do this by creating some monies and incentives behind it."
The first year of the demonstration focused on setting up the infrastructure for collecting demographic information, screening for social needs and sharing beneficiary data with the state Medicaid program to help inform the creation of quality benchmarks for improving care. The benchmarks will be tied to the payments as the demonstration progresses.
According to the Massachusetts Health and Hospital Association, which played a role in developing the waiver, all acute-care hospitals in the state met the requirements in 2023 and received incentive payments through the program.
Expectations of hospitals will increase over time. For example, those vying for the incentive payment in 2024 must initiate a performance improvement project in collaboration with an accountable care organization and devise a second project for the subsequent year.
To qualify for increased funding by the end of 2025, hospitals must collect self-reported data on race and ethnicity for at least 80% of MassHealth beneficiary patients, among other requirements. Facilities will also be required to achieve the Joint Commission's health equity certification by that year.
By 2026, hospitals will be assessed on their ability to improve quality and close disparities in care across various metrics chosen by CMS and state authorities. The metrics could include maternal health, access to care, primary care, pediatric care, chronic health outcomes, behavioral health, care coordination and patient experience.
And by 2027, the final year of the demonstration period, hospitals seeking to qualify for the payment must know the primary language, sexual orientation and gender identity of 80% of MassHealth beneficiaries. They must also demonstrate to-be-determined "meaningful improvements" in both the rates of social needs screening and their ability to track referrals and resulting health outcomes.
Laying the data-collection foundation
Executives at Tufts Medicine and Cape Cod Healthcare have worked across several divisions of their systems to coordinate the work necessary to meet the first-year requirements under the waiver program. Tasks included collecting patient data on race, ethnicity, language, disability, sexual orientation and gender identity; screening patients for health-related social needs, such as housing and food security; and improving access for patients with disabilities or limited English proficiency.
At Tufts Medicine, which has four hospitals, subject-matter experts and information technology specialists collaborated with members of the diversity, equity and inclusion department and the operations team to improve data-gathering and integrate the information into technology platforms' operational processes.
The work groups identified necessary additions to patient portals and intake documents and determined where to screen patients in various clinical contexts. The health system also added fields for demographic and social risk data to its electronic health record and conducted staff training sessions to ensure information collection occurs in appropriate settings. For instance, patients have the option to respond to questions prior to an appointment.
In that vein, Tufts launched the "We Ask Because We Care" campaign — a trust-building communications strategy modeled after one conceived by the New York-Presbyterian Dalio Center for Health Justice — to educate patients about how the health system utilizes demographic data and why the information is relevant to healthcare. It also established a network of community services for patient referrals and utilized tools like social care platform Findhelp to link patients with resources.
Osborn said Tufts is seeking to build capacity to track outcomes and administer equitable care. "This is going to be a continued process but we're really laying the foundation to have that happen," he said.
Cape Cod Healthcare, a two-hospital safety-net health system, had already initiated pilot programs for health-related social needs screening and included social-needs fields in its electronic health record. The organization needed to align the questions with MassHealth standards and expand its existing infrastructure to encompass 80 screening stations across its hospitals and ambulatory settings, said Chief Health Equity and Wellness Officer Dr. Kumara Sidhartha.
"The state of Massachusetts's Medicaid program puts health equity front and center, and the incentives are definitely significant enough to pay attention to for health systems," Sidhartha said.
In July 2023, the entire system started screening for social determinants. Cape Cod Healthcare has developed workflows for capturing demographic information and initiated efforts to stratify health outcomes by race, ethnicity and language to identify and address disparities in care, Sidhartha said.
Using the data, the health system identified disparities in high blood pressure among its patients and has developed a plan to improve those outcomes this year.
Correction: An earlier version of this article incorrectly said CMS authorized funding for the program in 2012.
