The Centers for Medicare & Medicaid Services (CMS) have provided general definitions for both health equity and health disparities. To CMS, health equity is “The attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” CMS takes their health disparities definition from the Centers for Disease Control and Prevention (CDC) as “Preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health, health quality, or health outcomes that are experienced by underserved populations.” Patient populations most prone to experiencing health disparities include “people from some racial and ethnic minority groups, people with disabilities, women, people who are LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersex, or other), people with limited English proficiency, and other groups.” CMS has also identified living in a rural area or being near or below the poverty level as associated with worse health outcomes.
Since 2021, the U.S. Department of Health and Human Services, CMS, and other federal agencies have emphasized achieving health equity as a common goal for hospitals, physicians, patients, and other stakeholders. CMS’ Center for Medicare & Medicaid Innovation (CMMI), the body assigned to create and vet alternative payment models, has made health equity a central feature in its overall strategy. A number of reports and action items have been produced in a short period of time. In 2021, federal agencies published the “CMS Mapping Medicare Disparities Tool,” the “Racial, Ethnic, and Gender Disparities in Health Care in Medicare Advantage” stratified report, and the CMMI “Accountable Health Communities Model.”
Federal agencies have relied upon several requests for information to assess, identify, and act on current gaps in measuring disparities and health equity. Requests for information have been a basis for CMS to gather perspectives on best practices and innovation from a variety of stakeholders to shape future regulatory initiatives. CMS started with a somewhat basic level of data collection. For instance, in 2021 and 2022, CMS requested information on how to standardize race and ethnicity data. CMS recognized that self-reported race and ethnicity is the gold standard for classifying an individual but that few organizations, including CMS, have consistently collected that information. Anesthesiologists, if not already, will begin to see their facilities collecting patient self-reported information.
CMS also proposed to develop and implement quality measures that would encourage standard data collection among hospitals and physicians. CMS has narrowed its focus on assessing the social drivers of health screening to food insecurity, housing instability, transportation problems, utility difficulties, and interpersonal safety. As CMS moves forward with these proposals, the question before health care stakeholders is whether an individual physician or group that identifies and understands the patient’s individual drivers of health will be empowered or have the resources necessary to address and improve that patient’s outcome or their access to care.
In recent comments to CMS, ASA supported further development and inclusion of health equity-related measures as part of a larger quality strategy. Quality measures that best capture health equity, as a starting point, could be built around patient self-reported demographics as well as preferred language, insurance type, education level, income, and home and food security. These screening questions would need to be standardized across the nation and across medical systems, facilities, and staff. However, capturing these self-reported measures in preoperative clinic visits prior to surgical procedures may present some obstacles for anesthesiologists, especially in how anesthesiologists would obtain standardized screening question responses and how they could consistently screen for these health equities in different practice settings.
Self-reported patient characteristics and standardized tools present other challenges for addressing disparities. A standardized process, tool, or assessment would help facility staff and physicians have a common understanding and benchmark for assessing patients. A core feature of this process should include provisions that collected data be shared between physicians, facilities, and health systems in a way to assess disparities and improve health equity. As mentioned above, self-reported patient characteristics are currently considered a gold standard, but CMS and others may wish to study the issue more closely. Many patients are reluctant to share personal information with physicians and facility staff for several reasons. Some patients may not understand how their race and ethnicity data may be used to measure quality, patient safety, and access to care. It is understandable that patients may hesitate to respond to questions of race and ethnicity, especially if they believe the collection of this data is intended to render inferior care. By creating a more transparent process, including patient education on why race and demographic data is being collected, hospitals and clinicians may be able to improve trust between the patient and their care team.
With regard to health equity, there may be several opportunities for anesthesiologists to contribute to better care, both at the individual level and within the facility. Anesthesiologists are often at the mercy of their facility to provide data, including patient demographics. If a hospital or facility could share reliable and comparable patient characteristics, the anesthesiologist could look at the application of best practices between patient populations. For instance, postoperative nausea of vomiting prophylaxis, which is a commonly collected measure, could be assessed based upon the medications that a patient received to demonstrate equitable care. Another potential measure might assess whether the anesthesia plan for a given procedure or as part of an enhanced recovery protocol was equitably carried out between population groups.
CMS and other payers may encourage greater care coordination efforts and referral systems by developing, testing, and validating methods for a physician to work with facility staff to identify community-based resources for specific patients. Each patient is unique and has specific needs that may affect their postoperative outcomes. An anesthesiologist is not necessarily trained to individually diagnose what is needed from a health equity perspective for an individual patient or to understand the community-based resources that may or may not be available for the patient. Instead, hospital leadership would need to work with anesthesiologists and others on developing a structure that could identify the appropriate services the patient may need.
The reality for anesthesiologists is that few, if any, characteristics identified by patients are likely to be collected by an individual or anesthesia group. Demographic information is often collected as part of an admission process and, from a patient or family perspective, should only be collected once during a perioperative episode. Since federal quality programs are focused on individual and group actions, attributing a facility-based measure where the data is generally collected by administrative staff instead of physicians or other eligible clinicians would present significant attribution challenges for anesthesiologists. ASA looks forward to how these measures will be implemented and how anesthesiologists can nonetheless contribute to larger facility goals for reducing disparities and improving health equity.
Although there are no current health equity measures for anesthesiologists to report via the Merit-based Incentive Payment System (MIPS), MIPS participants can nonetheless receive credit for health equity initiatives via the Improvement Activities performance category. Since 2021, CMS has finalized improvement activities that recognized groups using tools and resources to close disparities across communities; accepting clinicians for rotations in community practices in small, underserved, or rural areas; and implementing anti-racism plans using the CMS Disparities Impact Statement. Several other improvement activities are available as well.