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CMS Focus on Health Equity

Health Equity Terminology and Quality Measures

Measure developers need to use clear terminology when describing what and how their measures are addressing equity, social drivers/determinants of health (SDOH), and social risk factors.

In 2001, the Institute of Medicine, now the National Academy of Medicine, listed equitable care as one of six aims for improvement in health care. They defined equitable health care as "providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status."

In 2021, President Biden signed Executive Order (E.O.) 13985, which defined equity. CMS aligned their definition of health equity with E.O. 13985.

Health equity means 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, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factor that affect access to care and health outcomes.

The media and others often use the phrase social determinants of health or social drivers of health (SDOH) when discussing equity and often use social risk factors and SDOH interchangeably. Green and Zook (2019) note that everyone has social determinants of health (SDOH) (e.g., education, social and community context, health and health care, and neighborhood and built environment). Not everyone has social risk factors (e.g., food and housing insecurity, lack of transportation), things we know can affect health negatively. CMS defines (SDOH) as the conditions in the environment where people are born, live, work, play, and age. The question is what is the state of their SDOH?

Others (e.g., Lumpkin et al., 2021; Serchen et al., 2021), while acknowledging synonymous use, have noted the D in SDOH is drivers, not determinants as they are not determining anything. Others use driver in their description of determinants (Chandra et al., 2016; Kind & Golden, 2019).  Drivers are things that can affect health, both positive and negative. Serchen et al. (2021) note drivers are things "that can be influenced rather than fixed determinants that are immutable." Per the Cambridge Dictionary, to determine something is "to control or influence something directly, or to decide what will happen," whereas to drive is to provide impulse or motivation. Lumpkin et al. (2021) believe the health care sector is conflating social determinants of health, social needs, and social risk factors. They note this conflation obscures the distinction between screening patients for unmet social needs and navigating patients to basic resources in their community, and the need to address the underlying social determinants of health, which requires community- or societal-level action. Both phrases are in use at CMS.

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