CMS Continues Federal Push Toward Culturally Competent Healthcare

The Centers for Medicare & Medicaid Services (CMS) took two major steps toward implementing culturally competent care in 2023, with a focus on Medicare Advantage provisions. Herein is a look at what physicians need to know about the updated rules going into 2024.

In April, CMS finalized rules that expanded the list of populations to whom Medicare Advantage (MA) organizations must provide services in a culturally competent manner and to include providers’ cultural and linguistic capabilities in provider directories. The rules also require that MA organizations’ quality improvement programs include efforts to reduce disparities. In November, CMS followed up by requiring “culturally and linguistically appropriate” care in order to bill Medicare under a number of diagnostic codes within the Physician Fee Schedule for 2024.

CMS’s Definition of Culturally Competent Care

According to CMS, culturally competent care requires healthcare providers and health systems to deliver services that meet each patient’s social, cultural, and linguistic needs. This type of care aims to provide high-quality care to each patient, regardless of their background. To be effective, culturally competent care must take into consideration each patient’s race, ethnicity, nationality, language, literacy, gender, socioeconomic status, physical and mental ability, sexual orientation, occupation, as well as their individual values, beliefs, and behaviors about health and wellbeing.

According to Healthcare Compliance Pros, a team of compliance specialists who help healthcare providers and health systems to meet their regulatory requirements, putting culturally competent care into practice means:

• incorporating awareness and discussion of cross-cultural differences into one’s practice

• utilizing translators who speak the patient’s language

• strengthening one’s cross-cultural communication skills

• employing an inclusive, patient-centered decision-making process when developing a treatment plan

Rapidly Diversifying Nation Requires Greater Focus on Cultural Humility

The United States is diversifying faster than was ever anticipated, forcing healthcare systems to evolve quickly to keep up with the needs of the current and future patient population. According to the US Census Bureau, by 2019 nearly 40% of Americans identified with a race or ethnic group other than white, up from 20% in 1980. The white population share has decreased in all 50 states and in 98% of the nation’s major metropolitan areas, and, for the first time since the census began, more than half of the nation’s population aged 16 and younger now identify as a racial or ethnic minority.

With this changing population comes changing healthcare needs. Since 1980, the number of people living in the US who speak a language other than English at home nearly tripled and now accounts for nearly 1 in 5 patients. Non-native English speakers require healthcare providers who can effectively communicate with them and who are compassionate to their unique cultural needs and beliefs. While Spanish is, by far, the most commonly spoken non-English language in US homes, there is also a significant portion of the population who speak Chinese, Tagalog, Vietnamese, and Arabic in their own homes. Approximately 18 million people, or more than 1 in 20 people living in the US, report that they speak English less than “very well.”

Culturally competent care aims to improve high-quality, effective, patient-centered care. Studies have shown that non-English speakers are less satisfied with their care and report more problems with the care they received, that utilizing a family member for translation rather than a trained professional results in decreased satisfaction with care, and that less than half of those in need of an interpreter during a healthcare visit are regularly provided with one. These challenges are not new as the Institute of Medicine, noted back in 2003 that “racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patient’s insurance status and income, are controlled.”

Federal Government’s Efforts in Cultural and Linguistic Competence: A Brief History

The federal government has taken a broad approach to working toward a more culturally competent healthcare workforce. Over 20 years ago, the US Department of Health and Human Services (HHS), through the Office of Minority Health (OMH), released the federal National Culturally and Linguistically Appropriate Services (CLAS) Standards. Updated and enhanced in 2013, the CLAS Standards are a set of 15 recommended action steps that should be taken by healthcare providers, health systems, and policymakers in order to advance health equity, improve quality, and help eliminate healthcare disparities.

Several steps were taken to actualize the ideals of the CLAS Standards, including recent changes to Medicare, Medicaid, Rural Health Clinics, and Federally Qualified Health Centers.

Nearly a decade ago, the Protecting Access to Medicare Act of 2014 was signed into law, resulting in the creation of patient-centered Certified Community Behavioral Health Clinics. By law, these clinics must show cultural competence, including, specifically, when treating people with limited English proficiency, military service members, and veterans. Services provided must be respectful of, and responsive to, the health beliefs, practices, and needs of each patient. These clinics use culturally and linguistically appropriate screeners, tools and approaches that accommodate disabilities, and require ongoing staff training in cultural competence.

Federal Efforts Fold Into 2024 Physician Fee Schedule and Coding

CMS’ current efforts to integrate cultural competency standards into practice with the new Medicare Advantage (MA) requirements aim to be more specific. In addition to listing their cultural and linguistic capabilities in provider directories and using quality improvement programs to reduce disparities, practices must provide culturally competent care to people who:

• have limited English proficiency or reading skills

• are of ethnic, cultural, racial, or religious minorities

• live with disabilities

• identify as lesbian, gay, bisexual, or other diverse sexual orientations

• identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex

• live in rural areas and other areas with high levels of deprivation

• are otherwise adversely affected by persistent poverty or inequality

The agency’s November 2023 follow-up to this effort includes finalizing the Physician Fee Schedule for 2024. Under the new rules, Rural Health Clinics and Federally Qualified Health Centers will only receive payment for Community Health Integration (CHI) and Principal Illness Navigation (PIN) services if the services include:

• a person-centered assessment to understand the patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors

• communication with practitioners, home- and community-based service providers, hospitals, and skilled nursing facilities (or other healthcare facilities) regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors.

Further, after hearing years of feedback from practitioners across many specialties about the importance of social determinants of health (SDOH) on the healthcare of patients, Medicare has added a new, optional, stand-alone code (HCPCS code G0136), to cover the administration of a standardized, evidence-based SDOH Risk Assessment. The new code will pay providers to spend 5 to 15 minutes, not more often than every 6 months, to administer an SDOH Risk Assessment as part of a comprehensive social history when medically reasonable and necessary in relation to an E/M visit. The SDOH needs that are identified through the risk assessment must be documented in the medical record and may be documented using a set of ICD-10-CM codes known as “Z codes” (Z55 to Z65), which are used to document SDOH data.

More on 2024 coding changes.

Resources for Delivering Cultural Competency in Practice

To help ease the imperative-but-monumental shift that must occur in day-to-day practice in order to provide equitable, evidence-based, culturally competent care, the federal government has a number of tools and strategies for healthcare providers and healthcare systems.

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate healthcare disparities by establishing a blueprint for health and healthcare organizations.

The Organizational Cultural and Linguistic Competency Assessment Tool can help an organization to establish a baseline measure of current practices and capacities for cultural and linguistic competence, which enables organizations to set competence goals, develop competence strategies, and track progress toward competence outcomes.

CMS also published three issue briefs that highlight practices and tools that providers of long-term services and supports (LTSS) can use to improve organizational cultural competence, train direct care workers in cultural competence, and recruit and retain a diverse direct care workforce.

See also, Supporting a Diverse Medical Workforce without Affirmative Action.

The Health Resources and Services Administration (HRSA) has produced a Translation Toolkit, which includes resources in Japanese, Chuukese, Ilocano, Korean, Marshallese, Samoan, Tagalog, Chinese, Spanish, and Vietnamese.

CMS now publishes the “Medicare & You” handbook in Chinese, Korean, and Vietnamese.