🛡️ Public data only — no PHI permitted on this instance.

Health Equity / SDOH Scorecard

CMS Health Equity Index components · SDOH screening · equity investment ROI · demographic disparity flags — 1,660 corpus deals

Attributed Lives

176,300

LIS/Dual %

16.2%

HEI Score

0.885

HEI Points

88.5

Bonus Potential

$29.9M

HEI Measures

SDOH Domains

Corpus Deals

1,660

HEI Measure Components — LIS/Dual vs Non-LIS Performance

Measure	Domain	LIS/Dual	Non-LIS	Gap	Weight	Points
Breast Cancer Screening	Preventive	68.0%	78.0%	+10.0pp	12%	10
Colorectal Cancer Screening	Preventive	62.0%	72.0%	+10.0pp	12%	10
Controlling Blood Pressure	Chronic	58.0%	71.0%	+13.0pp	15%	12
Diabetes Care - HbA1c Poor Control	Chronic	32.0%	22.0%	-10.0pp	15%	12
Eye Exam for Diabetics	Chronic	65.0%	75.0%	+10.0pp	10%	10
Transitions of Care - Discharge Review	Care Coordination	52.0%	72.0%	+20.0pp	8%	8
Follow-Up After ED Visit (BH)	Behavioral	42.0%	55.0%	+13.0pp	8%	8
Osteoporosis Mgmt (Women 67-85)	Preventive	28.0%	45.0%	+17.0pp	5%	5
Flu Vaccine (65+)	Preventive	72.0%	80.0%	+8.0pp	8%	8
Plan All-Cause Readmission	Utilization	22.0%	14.0%	-8.0pp	7%	7

SDOH Screening Completion & Closed-Loop Referral

Domain	Screened	Positive Screen	Closed-Loop Referral	Intervention PMPY	ROI Score
Food Insecurity	52.0%	28.0%	42.0%	$185.00	72
Housing Instability	45.0%	18.0%	35.0%	$385.00	68
Transportation	62.0%	22.0%	68.0%	$125.00	78
Utility Needs	38.0%	14.0%	45.0%	$85.00	62
Interpersonal Safety	48.0%	8.0%	52.0%	$225.00	65
Social Isolation	42.0%	25.0%	38.0%	$95.00	60
Financial Strain	55.0%	32.0%	28.0%	$145.00	58
Health Literacy	72.0%	38.0%	55.0%	$55.00	72

Equity Investment Portfolio & ROI

Initiative	Category	Annual Cost ($M)	Lives Impacted	Outcome	HEI Δ	Star Bonus Impact ($M)
Transportation Partnership (Lyft/Uber Health)	Access	$1.80	42,000	12% ED reduction for non-drivers	+0.22	$2.85
Community Health Worker Program	Access	$3.20	28,500	18pp HEDIS uplift in target ZIPs	+0.38	$4.25
Food Pantry / Produce Rx	Nutrition	$2.10	15,800	1.2-point HbA1c reduction	+0.28	$3.15
Medicare-Medicaid Dual Care Coordinator	Coordination	$4.50	18,500	22% readmit reduction for duals	+0.42	$5.20
Language Line / Translator Services	Access	$1.20	125,000	30% LEP closed-gap uplift	+0.18	$2.15
Mobile Clinic (Rural/Urban Gap)	Access	$2.80	8,500	42% new-PCP visits	+0.32	$3.45
Behavioral Integration at FQHC	Behavioral	$3.50	22,000	55% improvement in follow-up rate	+0.48	$5.85
Rx Assistance / $0 Copay Program	Pharmacy	$2.40	85,000	18% adherence lift	+0.25	$2.95

Demographic Segment Performance & Disparity Flags

Segment	Pop (000)	Avg RAF	Preventive Util	ED/1000	HEDIS Composite	Disparity Flag
LIS / Dual Eligibles	28.5	1.62	58.0%	482	0.68	YES
Non-LIS Medicare	62.5	1.08	72.0%	285	0.81	NO
Hispanic / Latino	18.2	1.14	62.0%	395	0.72	YES
Black / African American	14.5	1.28	55.0%	465	0.69	YES
Asian / Pacific Islander	8.8	0.95	78.0%	225	0.85	NO
Rural Residents	22.5	1.22	54.0%	412	0.71	YES
English Limited Proficiency (LEP)	12.8	1.18	48.0%	445	0.65	YES
Disabled Under-65 Medicare	8.5	1.85	52.0%	625	0.62	YES

Equity Thesis: HEI score 0.885 (88/100 points). LIS/Dual population is 16.2% of book; 6 of 8 demographic segments show measurable disparity. Equity investment $21.5M yields estimated $29.9M Star bonus impact — positive ROI. Diabetes care and osteoporosis management show the widest gaps; transportation and community health worker investments have highest demonstrated ROI. CMS 2027 Stars calculation replaces the Reward Factor with HEI — making this scorecard directly tied to MA plan bonus payments and cut points.