Background:
The MassHealth Quality and Equity Incentive Program (MHQEIP), established under the 1115 Medicaid waiver, ties incentive payments to hospitals’ performance on equity and quality benchmarks. A core requirement of the program is the screening and reporting of health-related social needs (HRSN). While the use of administrative codes—specifically Z-codes (ICD-10), M-codes (CPT), and G-codes (CMS-specific)—is not mandated by MassHealth this year, this integration offers significant long-term benefits. Since implementation, hospitals across Massachusetts have reported substantial variation and difficulty in integrating these codes into electronic medical record (EMR) systems and billing workflows. Despite these challenges, MassHealth emphasizes the value of administrative coding: not only for identifying unmet social needs across the state, but also for informing community resource allocation and enhancing risk adjustment under the alternative payment models.
Objectives:
- To understand how hospitals are incentivized to implement HRSN screening through the incentive program and why this is important in the broader context of health equity
- To understand how hospitals are operationalizing HRSN screening and administrative coding in response to MHQEIP requirements
- To identify system-level barriers preventing seamless integration of HRSN data into EMR and claims workflows
- To develop policy recommendations that support alignment, standardization, and implementation feasibility
Methods:
- A review of the 2024 MassHealth Hospital Quality and Equity Strategic Plans submitted by all 60 hospitals and 20 ACOs
- Semi-structured interviews with key stakeholders from three large diverse health systems and one accountable care organization
- Thematic analysis comparing implementation challenges and opportunities across institutions
Results:
Three key challenges emerged:
- EMR Limitations: Lack of automated logic to trigger Z-, G-, or M-codes; reliance on manual chart review or custom reports
- Workflow Fragmentation: Disjointed intake platforms impede structured data capture and code administration
- Mandate Misalignment: Differing reporting frequencies and data formats across CMS, MassHealth, and Joint Commission create confusion and duplication
Future Directions:
- A statewide EMR stakeholder coalition to unify hospital voices and negotiate with vendors
- An open-source EMR integration guide tailored to HRSN coding
- Synchronized reporting requirements across regulatory agencies to reduce burden and improve compliance
Preceptor:
Dr. Clara Filipe (CMO), Erica Guimarães (Deputy Director)
The MassHealth | Office of Health Equity
