Health Equity Benchmark Adjustment (HEBA) – What ACOs Need to Know

Health Equity Framework

The goals for CMS and the Centers for Medicare and Medicaid Innovation (CMMI) for achieving health equity are described in the CMS Framework for Health Equity 2022–2032 and ultimately roll up to an overarching goal of improving true access to quality healthcare for all persons in Medicare and Medicaid programs. One of the concerns with the Medicare Advantage program historically was that plans were “cherry picking” patient populations that were predominantly white and in areas where there were not large health and social disparities. To encourage plans and practices to increase outreach to historically underserved populations, CMS included some options to assist with increased initial costs and potential increased higher costs that stem from patients not having access to healthcare now having the ability to manage their care with a primary care provider (PCP) as well as accounting for additional support needed for beneficiaries who live in areas without nutritious food options or transportation options.  

What Is the ACO REACH Health Equity Benchmark Adjustment (HEBA)?

The ACO REACH The Health Equity Benchmark Adjustment (HEBA) is a benchmark adjustment for ACO REACH contract holders to allow for adjustment of the ACO benchmark based on the Area Deprivation Index (ADI) as well as dual-eligible status (patients who have both Medicare and Medicaid) or receive a low-income subsidy status from CMS. The ADI score system was developed by the University of Wisconsin-Madison research team and is a census block based system measuring levels of economic disadvantage.

ACO REACH Benchmarks

 Each individual beneficiary is given a score for both the state and national level of deprivation of their census block with additional points assigned to beneficiaries who are dual eligible or receive a low-income subsidy status from CMS. Once all beneficiaries have been assigned a score and ranked, benchmark adjustments are as follows:

• +$30 per beneficiary per month (PBPM) for beneficiaries with a HEBA score in the top decile
• +$20 PBPM for beneficiaries in the second decile
• +$10 PBPM for beneficiaries in the third decile
• -$10 PBPM for beneficiaries in the bottom three deciles

PY2024 Model Update Adjusted Benchmarks

Before 2024, the upward adjustment was only for the top decile and the downward adjustment was for the bottom five deciles with a net neutral effect. The 2024 adjustment allows for increases in the benchmark for most ACOs. While the benchmark adjustment is given to the individual beneficiaries, the ACO benchmark is adjusted based on weighted averages in the beneficiary adjustments. 

Understanding Population Needs Through ADI Data

While ACOs are unable to change the location of their attributed and aligned beneficiaries, attention to the ADIs of the organization’s service location is key to understanding the population’s needs. Using the ADI tools such as the GeoHealth scores from Johns Hopkins ACG system can assist with targeting areas where beneficiaries who are your patients are already living for increased outreach including medical and non-medical outreach. One of our Acclivity clients was looking for areas to expand their presence that are underserved while also having to address staffing concerns for safety in some of the urban areas. When they pulled their patient data from the report inside of Activity, they found that the areas they serve that scored highest in deprivation were rural areas and not the inner city.  Another client reviewed the ADI data for their population to target their community outreach efforts. They found that they have areas of high deprivation that also showed high use of SNAP benefits for food and low available transportation. They pivoted their outreach planning to these specific non-medical needs that are important to the health outcomes of the population as well as increase their presence in the community as a resource. 

HEBA’s Impact on Goal of Accessible Quality Care

Understanding how HEBA can impact your organization’s benchmark as well as how targeting areas with high deprivation scores will impact the goal of accessible quality care for all is essential. CMS is continuing to review and adjust HEBA in the ACO REACH population to not penalize ACO contract holders for caring for those who are at highest risk.  Use of tools such as the Johns Hopkins ACG inside of Acclivity gives insight into your population to not only know where your population currently stands but where to focus the future growth of your organization. 

For additional help or information set up a quick meeting, or read more on our ACO REACH page.

Author:

Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions