Finding Answers Meets Bridging the Gap to Share Lessons Learned

Scott C. Cook, PhD

The Merck Foundation recently launched Bridging the Gap, a pioneering effort to address the social and medical causes of disparities in diabetes care in eight underserved communities across the United States. Its stakeholders are particularly interested in developing sustainable models that address the medical and social needs of vulnerable populations.  

I had the opportunity to facilitate a panel discussion with Bridging the Gap health care delivery stakeholders at their annual meeting in May. Like Finding Answers, Bridging the Gap is among a growing number of projects attempting to solve the complex puzzle of how to integrate payment reform and health care delivery reform to address disparities. We explored their experience working with payers specifically, and while each circumstance posed unique challenges and opportunities, some common themes emerged:

  • There exists a tension between one-size-fits-all standardization and tailored interventions. Some participants described negotiating with health care payers over whether they could utilize current payment models or whether it was necessary to create new ones to support a successful local health care disparities intervention. While payers are often motivated to standardize intervention models for application across a system that includes a wide variety of settings, the success of disparity-focused interventions is often based on being tailored to the needs of a specific patient population and the realities of the community.
  • Multiple payers require multiple negotiating strategies. Not surprisingly, Bridging the Gap grantees found that payer needs and priorities often varied by the size of the payer organization — whether they covered a region or were multi-state — and the related market forces. While most Bridging the Gap participants agreed that aiming to partner with the most dominant payer in the market would make the biggest impact, sometimes a quicker win can be achieved by reaching an agreement with a payer or purchaser with a smaller share of the market, such as a large local employer.
  • Some payers are in the information–seeking mindset. Some Bridging the Gap grantees assumed that payers, with their significant resources and personnel, would come to a meeting with a clear agenda for how they want to partner with a health care organization. However, solving disparities is a complex endeavor, and health plans are also struggling to find the right answers. Sometimes they look to health care delivery organizations to provide those answers, and come to the table with the goal of simply gaining more information that will help them build a strategy. Ultimately, it can take many discussions over a long period of time to discover whether a payer is ready to partner with a specific health care organization to address disparities.
  • The pressures of market competition can limit candor. Health care providers are often eager to share advances and lessons learned with other providers and organizations. In contrast, payers may be reluctant to speak of their specific needs and strategies because they are actively competing for market share. Many payers are focused on ways to maximize quality while reducing costs that, for example, might give them a competitive edge when negotiating for state Medicaid contracts. Both parties must anticipate these sensitivities and adjust expectations as they explore ways to integrate new payment and health care delivery models to address disparities.
  • The policy environment can pave the way for progress. Some Bridging the Gap grantee team members emphasized the importance of working at the state level to address health care delivery and payment policy. For example, working closely with state Medicaid agencies to revise policies or contracting processes in a manner that encourages payers to address disparities may establish the necessary groundwork for ultimately partnering with payers to address these issues. Bridging the Gap grantees recommended, at the very least, being aware of current state policies to inform negotiation strategies.
  • It takes time to build trust between payers and health care organizations.  There was widespread acknowledgement throughout the annual meeting that it takes much longer than expected to achieve the goal of partnering directly with payers to integrate payment and health care delivery reform. The process requires time to build trusting relationships with multiple people in different sectors of health care delivery and payment. Sometimes it takes working on smaller projects, with smaller goals, in order to build a track record from which to tackle the larger objective of eliminating disparities.

However, the different perspectives that health care organizations and payers bring to the table during discussions present not only potential challenges, but also the possibility of productive new ideas and perspectives. For example, health care organizations are typically better able to foresee when and how pay-for-performance programs might succeed or fail based on organizational culture. Payers, for their part, are typically well-equipped to suggest how a specific intervention can be scaled and disseminated on a regional or multi-state level.

Finally, our Bridging the Gap colleagues shared our own observations that many disparities in health and health care emerge, at least partly, because the populations and communities experiencing them lack the opportunity to fully exercise their own power and voices in our health care system. The Finding Answers program has learned through its grantees and technical assistance recipients that programs to reduce or eliminate disparities are more likely to succeed if they actively involve the patients and community members living with the disparity. As with any intervention aimed to eliminate disparities, it is important to partner with the patient community to design effective strategies to integrate payment and health care delivery reforms.


Scott Cook, PhD, is Deputy Director of Finding Answers: Solving Disparities Through Payment and Delivery System Reform.