Everyone’s Talking About Health Equity – But Are They Speaking the Same Language?

By Teresa Younkin, Senior Consultant

In today’s social, economic, and even political climate, the needs of disadvantaged, marginalized, and overlooked communities consistently make headlines — and with good reason. Whether it be at the local, state, or national level, policymakers and program developers do their best to bring much-needed resources to those in need of services. When it comes to healthcare, these communities have, for a myriad of reasons, consistently lacked access to quality care and support services. These shortcomings were brought into sharp focus during the early days of the pandemic, when it became evident that people living in certain zip codes across the country were not as likely/able to access testing and eventually vaccination services as their counterparts in more advantaged areas. As the pandemic wore on, the need for a more equitable healthcare playing field became all too evident.

That’s not to say, of course, that the concept of health equity was new. While the phrase has certainly seen its fair share of marketing airtime over the past several years, the idea that, according to the Centers for Disease Control and Prevention, “everyone has a fair and just opportunity to attain their highest level of health” stretches back well before COVID-19. History buffs will appreciate the fact that health equity has been on the minds of public health and social medicine professionals as far back as the mid-1800s, when, according to a 2017 report from Princeton University researchers, “visionary public health leaders and social critics recognized that social and class inequalities led to inequities in health.” Anyone who has ever read “The Jungle” by Upton Sinclair will have an idea of the pervasive inequalities that helped to eventually coin the health equity phrase.

That same report, published before today’s level of health equity awareness, dives into the symbiotic relationship between health equity and social determinants of health (SDOH) – defined by the Department of Health and Human Services as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

Health Equity and Social Determinants of Health Go Hand in Hand

As anyone working anywhere in health care today can attest, identifying, gathering, and measuring data related to SDOH are vital to successful development and management of health equity strategies. And therein lies the rub: Providers, payers, government agencies, and even patients themselves must be able to work with terminology and data that are standardized and shareable – two characteristics with which healthcare has traditionally struggled.

Despite these data challenges, health equity improvement efforts have become part of almost every health care stakeholder’s 2023 initiatives. There are, however, many uncharted steps between collecting the right data, including social determinants, and using it effectively to improve access to care and outcomes for underserved groups. For example, when talking about equitable access to care, the number of clinics within a particular zip code may increase, but if the clinic hours don’t accommodate low-wage service workers who work long shifts, access is not being improved. Patients would still need to take time off from work to access care, resulting in lost wages. With the right kind of SDOH data, healthcare stakeholders could pinpoint the precise kinds of care and services specific communities need most – and the hours during which they should be offered – and then measure how effectively those care and support services are delivered.

Recognizing SDOH Data Challenges

By now, those working in health care are all too aware of the importance SDOH play in identifying groups of people who may benefit from care interventions or community-based services. According to a recent study by the American Health Information Management Association, 78% of health care organizations collect SDOH-related data. Most healthcare providers have their own SDOH assessment tools that are used at the point of care. Once captured, however, those data are typically siloed in the provider’s electronic health record (EHR) or other data repository, rendering them undiscoverable or unusable by other healthcare entities, such as local community organizations and support groups. As it stands today, a provider who refers a patient to a local food bank may never know if the patient was able to access those services.

Many early adopters of the whole-person healthcare model have implemented data collection programs ahead of policy requirements, including social needs questions during patient enrollment/intake and at appointments with providers. Yet these innovators struggle with effectively capturing data, citing their biggest concern as a lack of agreed-upon terminology and classification codes, even within their own organizations. Different departments within the same health system are using inconsistent terminology to categorize and report SDOH data, resulting in an inability to share the information or act on it in a meaningful way.

It is this lack of SDOH information standardization and exchange that contributes to ongoing health inequities. Thankfully, many public- and private-sector efforts are underway to bridge this information exchange gap.

Data-Sharing Improvement Efforts Underway

As with all matters involving interoperability, the federal government has for the past several years – if not longer – created resources, programs, and policies dedicated to helping health care stakeholders effectively share data focusing on health equity. Its Healthy People initiative, for example, launched in 1980, is now in its fifth iteration. Healthy People 2030 focuses on SDOH in five areas – economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. The Health Level 7 (HL7)-affiliated Gravity Project, a public-private collaborative launched in 2019 to build consensus-driven standards for SDOH data, helped shape the Healthy People 2030 standards with the publication of evidence-based data sets for 17 SDOH domains that align with the five aforementioned areas. The standards are recognized and recommended in such federal programs as the Centers for Medicare and Medicaid Services’ (CMS) Medicare Advantage special needs plans (SNPs) and by the National Committee for Quality Assurance (NCQA).

Gravity team members representing payers, providers, government agencies, and healthcare companies are focused on establishing universal terminology and technical standards for SDOH data to improve interoperability and usability. The collaborative continues to make significant strides in SDOH data interoperability with use case pilot programs focused on creating and testing an implementation guide for screening and referral tools. It is seeking project sponsors committed to advancing the standardization of SDOH data. For more information, visit thegravityproject.net.

More recent efforts include those of the Sync for Social Needs Coalition, a team of leading healthcare organizations and technology vendors aiming to integrate nutritional information within a patient’s EHR via a standardized, Fast Healthcare Interoperability Resources (FHIR)-based approach. Participants work to create consensus for data-sharing standards and pilot real-world testing of HL7 FHIR-based tools for SDOH data collection and sharing. Tools currently being tested include the CMS Accountable Health Communities Tool and the FHIR US Core Implementation Guide, chosen because 2023 CMS regulations require their use for the collection of SDOH data for participation in value-based care incentive programs.

As of January 2023, NCQA requires social care quality measures for health plans to participate in the Healthcare Effectiveness Data and Information Set (HEDIS) program. By January 2024, CMS will require all Medicare Advantage SNPs to include at least one question from specified screening tools from three domains – food security, housing stability, and transportation access. CMS has also added social care quality measures to the Merit-based Incentive Payment System and Inpatient Quality Reporting. Though voluntary, scores earned by the reporting of these measures bring advantages to program participants. While the health plan-focused initiatives specify which screening tools to use, other programs leave the choice up to participants. A comparison table of the most widely used social needs screening tools can be accessed here.

The more recent publication of the Social Determinants of Health Information Exchange Toolkit by CMS and the Office of the National Coordinator for Health Information Technology is intended to advance SDOH information exchange for stakeholders of all experience levels by providing a foundational framework to assist in planning, design, implementation, and evaluation processes of SDOH information-exchange initiatives.

Internal Efforts Will Be Key to SDOH Data Sharing for Health Equity Success

While resources and programs may seem to abound, it is important to recognize that internal efforts involving health equity objectives are necessary first steps to joining broader health equity initiatives. Before adding SDOH assessment tools to collect data, it may be necessary to revisit existing data use agreements or establish new agreements with community-based services. Experts at Point-of-Care Partners are often sought for consultation on creating strategies to collect data that help identify and mitigate those factors perpetuating disparities in health equity, obtaining consent in a way that builds trust, and leveraging standardized data to avoid implicit bias.

Point-of-Care Partners subject matter experts hold leadership positions within many of the HL7 FHIR-based accelerator programs and can share the latest news and their insights about what’s coming next in the area of SDOH data sharing and health equity initiatives. Reach out to Teresa.Younkin@pocp.com with any questions or for help prioritizing 2023 health equity efforts.