Advancing A Health System Transformation Agenda Focused On Achieving Health Equity

This originally appeared in Health Affairs

There has been an important and ongoing effort over the past decade to address the manifest failures of our health care system by changing payment and provider organization to reward value and not volume. But transformation efforts largely ignore one of our system’s most fundamental problems: persistent, extensive, severe, and costly health and health care inequities based on race, ethnicity, and geography, among other factors. Health system transformation presents a valuable opportunity to accelerate the reduction of health and health care inequities. But it also poses a serious risk to communities already facing systematic inequities. Depending on how they are designed, new payment systems could incentivize providers either to deliver holistic care tailored to the needs of people confronting multiple barriers to good health and high-quality health care or to avoid patients with more complex needs. Assigning providers financial risk for their patients’ outcomes could either incentivize and enable them to build out comprehensive care management programs or pressure them to reduce health care use among people who are already underusing needed care. And imposing penalties for poor quality could either spur improvements in the quality of care provided in safety-net facilities or reduce treatment capacity in already underserved areas.

Policy makers in the health system transformation sector have not sufficiently prioritized health equity. The impact of delivery and payment reforms on communities of color and other underserved communities have rarely been the focus of transformation efforts, and strategies intentionally designed to narrow these gaps have been few and far between. Additionally, the most affected communities and health equity advocates have not been adequately represented or engaged in these efforts.

To catalyze action at the national, state, and local levels—with the goal of achieving a transformed health care system that consistently provides high-quality, high-value care for everyone—Families USA has partnered with national and state health equity advocates and experts to launch the Health Equity Task Force for Delivery and Payment Transformation. The task force aims to develop and advance a consumer-, community-, and health equity-focused health care transformation agenda.

Creating A Framework To Advance Health Equity And Value

The Health Equity Task Force for Delivery and Payment Transformation was created to bring together state and national health equity thought leaders to catalyze much needed action that leverages health system transformation for the benefit of those whom the health system is leaving behind.

Our first task was to lay out a rubric for assessing the potential impact of new initiatives on equity, a conceptual framework to organize the very broad topics of delivery and payment reform and health equity, and a menu of policy options to consider. The Task Force’s first publication, A Framework for Advancing Health Equity and Value: Policy Options for Reducing Health Inequities by Transforming Health Care Delivery and Payment Systems, is envisioned as a resource for policy development and prioritization for health equity and health system transformation leaders.

To help evaluate whether specific payment reform models and initiatives are reducing inequities or intensifying them, we developed a three-step analytical rubric:

• Is there a disparate impact on particular communities? The design and evaluation of payment models should attend to which groups or communities are benefiting from the model and which may be bearing the brunt of negative consequences. This requires stratified or disaggregated data, or both. One central question is whether a model results in a net redistribution of resources from providers who care for more complex patients with more risk factors (who are more likely to have lower incomes and be people of color) to providers who care for less complex, lower-risk patients (who are more likely to be white and have higher incomes).
• Is risk adjustment effectively accounting for clinical and social risk? There is concern that, to date, risk adjustment methods are incomplete and “not sophisticated enough to reliably distinguish poor-quality care from high medical and social risk.” Areas of concern include the appropriate inclusion of individual social risk factors (such as race, ethnicity, and functional status) and of neighborhood-level risk factors (such as concentrated poverty and rurality). Yet, it is also critical that risk adjustment not mask poor-quality care and persistent quality inequities.
• Are underlying resource inequities taken into account? Payment reform models must account for wide disparities in the resources providers have at their disposal, both within their institutions and in their communities. For example, many safety-net, rural, and community hospitals are operating under financially precarious conditions that leave little room to invest in quality improvement and in expanding services that would improve patient outcomes and their metrics. More broadly, in chronically under-resourced low-income and rural communities, many of the community-based clinical and social services and supports that are critical to improving health outcomes outside of the hospital or clinic may simply not exist.

Policy Options For Health Equity-Focused Transformation

In A Framework for Advancing Health Equity and Value, we synthesize existing academic research and analysis to develop a comprehensive set of policy options for advocates and policy makers to consider in leveraging health system transformation to advance health equity. These options—more than 80 in total—pertain to federal, state, and private-sector policy arenas, organized under six policy domains.

Payment Systems That Sustain And Reward High-Quality, Equitable Health Care

The financial underpinnings of the health care system must be aligned with the goal of reducing inequities, in addition to increasing quality and reducing costs. Policies under this domain may include:

• Incorporating robust risk adjustment for social risk factors into all risk-based payment programs.
• Requiring that payment models’ quality and cost incentives include explicit equity measures, both in Medicare and in Medicaid.
• Expanding the geographic areas and services eligible for telehealth reimbursement across all payers and removing other regulatory barriers to using telehealth.

Investments To Support Safety-Net And Small Community Providers In Delivery System Reform

Safety-net and small community providers face unique barriers to implementing new value-based payment models. Many of these models require significant upfront investments that these providers may be unable to make. Policies may include:

• Using Medicaid waiver funding to support upfront investments in safety-net and small community providers.
• Establishing a new Center for Medicare and Medicaid Innovation (Innovation Center) program to support safety-net and small community providers.
• Expanding Medicare Access and CHIP Reauthorization Act (MACRA) implementation support for small, underserved, and rural practices.

Building Robust And Well-Resourced Community Partnerships

Given the importance of socioeconomic factors and community context in shaping health, providers that want to move the needle on health outcomes will need to work beyond the walls of their institutions. Especially in communities facing the effects of discrimination and historical mistreatment by the health care system, providers should partner with and invest in trusted community-based organizations. Policies to support this goal may include:

• Directing the Innovation Center to develop a State Innovation Model (SIM)-like program that is explicitly focused on health equity.
• Strengthening accountability under the community benefit requirements that all nonprofit community hospitals must meet, and creating similar community investment requirements for other hospitals that receive federal funds. A similar policy could apply to health plans, including Medicaid managed care organizations.
• Setting up regional information technology hubs that underresourced community-based organizations can plug into so they can connect to health care providers to enable smooth referrals for community-based social services and supports, care coordination, and information sharing to provide high-quality, culturally centered, and language-accessible care.

Ensuring A Transparent And Representative Evidence Base

Improving the evidence base so that it reflects the diversity of our population is essential to developing more accurate clinical guidelines. Similarly, transparency about the limitations of the data used to determine treatment guidelines is needed so that patients, their doctors, and payers can make more appropriate care decisions. Policies to support this goal may include:

• Mandating improved reporting and analysis of demographic characteristics in clinical and delivery systems research and evaluation.
• Supporting the generation of more community-specific health system and delivery research, such as by reauthorizing the Patient-Centered Outcomes Research Institute.

Equity-Focused Measurement That Accelerates Reductions In Health Inequities

Measurement is an increasingly important factor in value-based payment and quality improvement. For new payment models to effectively reward equity, there must be equity-focused metrics tied to payment. Policies to support this goal may include:

• Requiring health care organizations to report performance data stratified by race, ethnicity, language, socioeconomic status, sex, gender identity, sexual orientation, disability, and other demographic factors.
• Prioritizing the development and use of disparities-sensitive and health equity measures.

Growing A Diverse Health Care Workforce That Drives Equity And Value

The overall US health care workforce must be more ethnically and racially diverse, better distributed geographically, and inclusive of a broader array of jobs—including primary care providers, mid-level providers, community health workers and promotores, and peer support specialists. Policies to support this goal may include:

• Increasing the diversity of traditional health care providers and health system leaders by expanding pipeline programs and other supports and incentives for students and providers from underrepresented groups and expanding opportunities for training in underserved areas.
• Promoting the sustainable use and integration of community health workers and similar community care team members.
• Promoting the use and integration of mid-level providers into care teams.

An Overarching Imperative: Include Communities Of Color In Transformation

Finally, the framework describes one overarching priority that cuts across all of the policy domains: ensuring the effective inclusion of the voices and priorities of communities of color, and other disadvantaged groups, in decision making. This inclusion must span policy development, implementation, and evaluation for it to be truly meaningful. Given the complexity of delivery and payment reform, and the limited experience leaders from communities of color have had in this field, meaningful inclusion will require concerted strategies and dedicated resources.

The Time To Act Is Now

The years immediately following the passage of the Affordable Care Act were a unique and exciting time in the field of health system transformation: a time of national and state-level innovation and experimentation at scale, with real engagement of the provider and payer sectors. But those years were also a missed opportunity to focus transformation efforts on health inequity. As we think about how best to move system transformation efforts forward in 2018 and beyond, the Health Equity Task Force for Delivery and Payment Transformation will be working to make sure that we do not miss that opportunity again.