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How MACRA Can Reduce Health Disparities

By Ellen Albritton,


Recently, Families USA submitted comments on a proposed rule from CMS for how it will implement the second year of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA was passed in 2015 with bipartisan support to help drive the health care system to one that rewards value instead of volume.

Efforts to shift to a value-based health care system create an opportunity to improve the quality of care and health outcomes, save money for consumers and the health care system as a whole, and drive reductions in health disparities. But such positive outcomes from payment and delivery reform efforts are not guaranteed. There are some elements of this proposed rule that can help reduce health disparities, but a real commitment to health equity requires additional steps from CMS.

Reducing health disparities must be a priority for all payment and delivery reform efforts

Although the transition to a value-based health care system presents an enormous opportunity to make significant progress on reducing health disparities, there is also a risk that it could make health disparities worse. A key risk is that safety net providers whose patients face more social barriers to accessing care and being healthy will receive undeserved financial penalties.

We are pleased that CMS is proposing some specific changes this year that can help achieve health equity. Two particularly important examples of this are:

  • Incentivizing the use of community health workers (CHWs): Under one track of MACRA, providers have to engage in a certain number of “improvement activities.” There are a number of evidence-based interventions providers can choose from, and, as we strongly encouraged in our comments on last year’s proposed rule, CMS has added an activity called “Provide Clinical-Community Linkages” that relies on the utilization of CHWs. We know that use of CHWs can be an effective strategy for reducing disparities.
  • Bonus points for complex patients: CMS proposes adding bonus points to a provider’s final score (which determines their payment adjustment) to account for the proportion of their patients with more adverse social factors affecting their care.  This is an important “fix” to make sure providers with a higher proportion of these patients are not unfairly penalized, but CMS should also continue engaging with these providers and other stakeholders to design a more systematic approach to this challenge.

However, CMS needs to take additional steps to ensure that MACRA is really being used to drive reductions in health care disparities. Two examples include:

  • ​Disaggregation of quality measures by demographic factors: Breaking out quality measures by different demographic factors, including race and ethnicity, primary language, etc., is necessary in order to identify and ultimately reduce health disparities. CMS should initially incentivize, but ultimately require, this disaggregated reporting of quality measures for providers under MACRA.
  • Requiring all providers to implement disparities-reducing activities: One category of improvement activities that providers can choose from is “achieving health equity.” Reducing health disparities should be a central goal of all payment and delivery reform efforts if our country is going to make progress on our longstanding and widespread health inequities.  We recommend that CMS prioritize adding new activities to this category, and to ultimately require all providers to implement at least one activity from this category.