Advancing Equity in Value-Based Care

Emmy H. Ganos
Andrea M. Ducas
Marshall H. Chin, MD, MPH

The trend toward value-based care is accelerating, and is more urgent as the climbing costs of care threaten gains in health coverage. As the field is moving toward new ways of paying for value, attention to health care disparities is sorely lacking. Not for lack of need — since the publication of the Institute of Medicine’s Unequal Treatment report, we’ve seen evidence that progress in reducing disparities in care has painfully been slow, or in some cases nonexistent. The field has increasingly recognized that social needs matter for people’s health, but experimentation with risk adjustment has shown that we can’t simply “adjust away” differences — people who are influenced by negative social determinants of health aren’t going to get tailored and higher-quality health care by risk adjusting alone, or even by “paying for value.” Yet we also know that, apart from what happens outside a doctor’s office or hospital, unacceptable gaps remain in the diagnosis and treatment of patients across race, ethnicity, gender, language, and sexual orientation.

With so much attention on value-based care, it seems a natural opportunity to bring equity into focus in the design of payment and delivery system reforms. We know, for example, that without actually measuring disparities in the health of patient populations, and working to address them, we are unlikely to see real progress. And so many payment changes necessitate a deep focus on data analysis to support changes to care delivery that work for different people. Yet frustratingly, the field has not seen prominent examples of organizations placing equity front and center in designing new ways to deliver and pay for care. A group of health care innovators funded by the Robert Wood Johnson Foundation’s Finding Answers program has set out to change that.

Last month, three Finding Answers grantees presented at the AcademyHealth Annual Research Meeting. They revealed how they explicitly designed payment and delivery system reforms to prioritize reducing disparities within their patient populations. These grantees are working to improve care for diabetes and hypertension, care for dental caries, and postpartum care; they are working with rural, suburban, and urban populations, with patients with low incomes and from diverse racial and ethnic backgrounds. Each has uncovered valuable insights on how taking an equity lens in designing payment innovations can lead to new and better ways of providing care. We’re excited to share the following highlights:

  • Dig into your data—it can be the “wakeup call” you need. In suburban Virginia, care providers at FQHC-look-alike clinics for uninsured, low-income Fairfax County residents were sure that they were treating all their patients equally well. When researchers at George Mason University took a dive into the data, however, they found a somewhat different story. Diabetes control, hypertension control, and cervical cancer screening rates differed for the clinic’s primarily Spanish-speaking population and the clinic’s non-Hispanic patients. Seeing the performance data by ethnicity was a wake-up call for the care providers. They immediately wanted to both understand the source of these disparities in outcomes and find ways to address them.
    Fairfax County, the clinic’s primary payer, allowed clinic operators to provide team-based incentive payments for closing gaps and improving care performance for patients with the greatest need. Clinical performance data from the EHR were delivered to clinical teams monthly along with the team-based incentive, and performance was discussed at team meetings and huddles. The team from Finding Answers provided technical assistance, and helped the project team to design and conduct root-cause analyses to understand how to best reform care delivery to meet patient’s needs.
  • Align the incentives. New York’s Icahn School of Medicine at Mount Sinai had a similar experience bringing performance data to providers. Creating a “Disparities Dashboard” helped providers to see where they could improve, and increased motivation to make the changes necessary to improve health equity. Postpartum care offers an opportunity to impact the health of underserved women, and Mount Sinai providers knew that their Medicaid population was not receiving timely postpartum care at the same rates as commercially insured patients. But addressing this issue required expensive changes to the care team — embedding a care coordinator and a social worker — and they thought that small financial incentives to improve could help provider performance, too. By tying performance targets to a payment reform that included infrastructure money for the additional team members, Mount Sinai was able to significantly increase the proportion of women who received timely postpartum visits, and improve care and satisfaction for their patients. This could potentially help prevent future poor health outcomes. 
  • Look for ways to risk-target, not just risk-adjust. As helpful as understanding what the social determinants of health are, we can’t just use them as a proxy for specific health or care needs. Risk adjusting performance scores or payment can help avoid penalizing safety-net institutions caring for patients with social risk factors, but it’s not a substitute for tailoring care delivery to patients’ individualized needs, or a substitute for working to improve quality. The University of Washington’s work with Advantage Dental demonstrated this issue clearly. By conducting dental risk assessments with children in rural Oregon, going out into schools and WIC centers to reach more kids, Advantage was able to deploy resources much more effectively. Advantage Dental provided routine preventive care for low-risk children in the community through expanded-practice dental hygienists, and provided curative care for high-risk patients with dental caries in dentists’ offices.
    “Poverty is not a proxy for risk of tooth decay!” explained Peter Milgrom, DDS, the project director for the U Washington project. Advantage Dental improved value by stratifying Medicaid patients by dental risk and tailoring care appropriately. By providing incentives to the care team for community outreach and for providing dental screenings for many, many more children in community settings, the project is improving access to preventive and curative dental care for low-income and rural residents. 

After working with dozens of health systems, Finding Answers knows that there is no one-size-fits-all solution for reducing disparities. But after more than a decade’s worth of research, providers do have an evidence-informed roadmap to help plot their own course. What’s been missing to date from that roadmap is evidence on how to codify the “business case” for equity. We believe, and our grantees are demonstrating, that approaching payment and delivery system reform with an equity lens changes the way providers think about and design health care delivery systems.

We have to do more to put health equity front and center in the push toward value-based care. If your organization is considering ways to build an equity focus into new payment models, please let us know. We’d love to hear and learn from you. And we look forward to sharing what we are learning from our investments in the months to come.


Author affiliations:

Emmy H. Ganos, Andrea M. Ducas: Robert Wood Johnson Foundation

Marshall H. Chin: University of Chicago and Robert Wood Johnson Foundation Finding Answers: Solving Disparities Through Payment and Delivery System Reform Program Office.