New CMS Rules for Digital Literacy Screening

New rules from The Centers for Medicare and Medicaid Services (CMS) for digital literacy screening and education by Medicare Advantage (MA) organizations could be game-changers for digital inclusion and for health equity.  Five in particular that stand out:

1. Identify People with Digital Readiness Gaps: Recognizing that “Low digital health literacy is one of the most significant obstacles in achieving telehealth equity,” CMS recently published a final rule requiring that MA health plans “develop and maintain procedures to identify and offer digital health education to enrollees with low digital health literacy to assist with accessing any medically necessary covered telehealth benefits.” Specifically, the rules now require “a digital literacy screening program or other similar procedure to identify current enrollees with low digital literacy.”
2. Education: Recognizing low digital literacy as a barrier to telehealth use, new rules require that MA plans “offer digital health education to enrollees with low digital health literacy to assist with accessing any medically necessary covered benefits” that are offered through non face-to-face methods.
3. Advancing equity: To achieve policy goals around health equity, CMS will now “require MA organizations to incorporate one or more activities into their overall QI [Quality Improvement] program that reduce disparities in health and health care among their enrollees.” Example activities include “improving communication, developing and using linguistically and culturally appropriate materials (to distribute to enrollees or use in communicating with enrollees), hiring bilingual staff, community outreach, or similar activities.”
4. Reporting: While CMS is not requiring any reporting on the efforts, the organization “must make information about its digital health literacy screening and digital health education program available to CMS upon request.”
5. Provision of devices and data: Finally, the rules refer to the allowability of an MA program to provide devices and data: “In addition, if an MA organization offers enrollees assistance with any necessary telehealth technology—for instance, if the MA organization provides limited use smartphones/tablets or cellular data plans as supplemental benefits in order to aid in the use of telehealth services….” However, the rules then refer to a host of restrictions including “that devices must only be used for primarily health related purposes (and cellular data plans can only be provided if use of these plans is locked.

Is all this Flexibility Needed?

These measures are, as noted, “a first step for MA organizations to assess the landscape of health equity in telehealth in their plans and help enrollees navigate telehealth.” Requirements around screening, and  education are intentionally left flexible with a “degree of discretion… in the procedures developed and used to identify enrollees with low digital health literacy and the digital health education services the MA organization provides for those enrollees.” Let’s look more closely at each area:

Screening: CMS bases the offer of flexibility around screening on a lack of evidence and best practices: “CMS encourages MA organizations to research current trends and successes in the field when developing their own methods to identify enrollees with low digital health literacy.”  I’m proud to say, CMS cites the blog I wrote on digital literacy for the Telehealth Equity Coalition in offering a screening strategy: “CMS anticipates that some MA organizations could ask enrollees, for example, if they have internet access and reliable connectivity, if they have a device that meets appropriate telehealth system requirements, if they use email, if they can download a mobile app, or if they can change applicable settings on a device (for example, browser or camera settings), as a means to identify which enrollees have low digital heath literacy.” It would be nice, as a next step, to identify funding for studies to validate screening instruments.  I use the plural for instrument here because, as I’ve explained elsewhere, the language used in digital readiness screening must precisely reflect the population being screened, the screening circumstances, and intended measures to address identified gap.  At the same time, health plans could work with providers to identify patients that have never used telehealth and don’t log into the patient portal as priorities for screening.  Contact Public Health Innovators for assistance in developing and validating your screening instrument or using automated methods to identify patients with digital readiness gaps.

Education: Similarly, “CMS did not propose to identify explicit parameters for this digital health education requirement….[choosing] to keep it flexible and allow for innovation in this area by MA organizations.”  They do, however, offer an extensive list of example educational strategies:  “distributing educational materials about how to access certain telehealth technologies in multiple languages, including sign language, and in alternative formats; holding digital health literacy workshops; integrating digital health coaching; offering enrollees in-person digital health navigators; and partnering with local libraries and/or community centers that offer digital health education services and supports.”  In general, this is a good list except we know that merely distributing materials does not work.  Best practices from the fields of adult basic education and the emerging digital navigation profession suggest the need to use strategies that recognize the unique dimensions of learning technology, and learning differences for groups that experience different barriers to technology.  For example, younger populations may lack the fear that is common to older populations while yet lack fundamental digital skills.  Thus, I especially recommend partnering with local digital inclusion organizations for digital skill training.  See the Digital Medicine Society’s Toolkit for Inclusive Deployment of Digital Technology in Health Care for which I provided digital inclusion subject matter expertise on behalf of the National Digital Inclusion Alliance.  To turbocharge this strategy, consider training community health workers to do digital readiness screening and education within the healthcare sector, and certifying Digital Navigators, much as CHWs are being certified to perform other services in healthcare.

Culturally Competent Care for Health Equity: To “clarify the broad application“ of health equity goals, new rules specify groups that should be considered for the provision of services “in a culturally competent manner.”  While “amending the list of populations” to include people in categories shown in the table below, the rules also strongly encourage “MA organizations and their contracted providers to review …new [federal civil rights]  guidance issued by HHS and DOJ [regarding accessibility and language proficiency] to ensure compliance.”  In other words, it’s too complicated and fast-moving for us to write in rules so we’ll let you figure it out?  Also, wouldn’t it be nice if these groups aligned with the “covered population groups” that the National Telecommunications and Information Administration requires be considered in Digital Equity Act Plans?

For your convenience, the Table below shows a crosswalk of population groups detailed in the Digital Equity Act and those of concern for Medicare Advantage plans:

Reporting:  CMS noted that the purpose of requiring that data be made available upon request was to allow CMS to monitor the impact of the new requirement for these programs on MA organizations, providers, enrollees, and the MA program as a whole.”   They further offered a list of information that they may request including “statistics on the number of enrollees identified with low digital health literacy and receiving digital health education, manner(s) or method of digital health literacy screening and digital health education, financial impact of the programs on the MA organization, evaluations of effectiveness of digital health literacy interventions, and demonstration of compliance with the requirements.” Priority 1 of the 2022 CMS Framework for Health Equity is to “expand the Collection, Reporting and Analysis of Standardized data.  Let’s hope that detailing reporting standards, and requiring their submission will come soon.  Public Health Innovators would be delighted to convene a group of experts to specify data standards here.

Provision of devices and dataplans:  The overwhelming contribution of social needs to health status is fully accepted by health care funders such as CMS. “Create social, physical, and economic environments that promote attaining the full potential for health and wellbeing for all” is one of Healthy People 2030’s 5 overarching goals.   With 112 citations of our 2021 article, and new ones added every week, digital inclusion appears to be squarely, if unofficially, recognized as a super social determinant of health. The notion of providing devices and data to overcome a barrier to telehealth, but limiting their use to narrow health care purposes seems short-sighted, to put it mildly.

So, my final assessment of new CMS Digital Health Literacy Rules:

The new rules will encourage MA plans to screen patients for digital literacy and address their needs.  Flexibility is warranted now in creating screening questions and digital literacy educational strategies, but these should move quickly toward using evidence–based practices as they become known.  The limitation on using devices for narrowly-defined health related purposes should be eliminated, and clear reporting standards should be developed and required.  Greater interactions between the health and digital inclusion communities will ensure that best practices are used.