George Mason University

Reducing Disparities in a Diverse, Uninsured Population by Motivating the Whole Care Team


“Many clinicians are nervous about being held responsible for performance dependent on patient behavior. So we focus more on care processes and help the teams understand that it’s possible to improve gaps in care and health outcomes, even when patient behavior plays a key role.”

–Len M. Nichols, PhD, Project Director

Professor, George Mason University

Click here for an interview with Dr. Nichols about what his team has learned so far.

Click here to contact Dr. Nichols about this project.


Hispanic patients at Fairfax County, Virginia’s, safety-net clinics are more likely to receive “high performance” care for cervical cancer screening, diabetes control, and hypertension control than non-Hispanic patients. Fairfax County and its clinical partners—originally Molina Healthcare and now Inova Health System—want to extend the same quality of care to the diverse, multilingual non-Hispanic population.



Fairfax County, in Northern Virginia, runs a Community Health Care Network (CHCN) of clinics for the 8 percent of its population (about 100,000 people) who are uninsured. Due to the high population of Spanish-speaking patients, Community Health Care Network (CHCN) clinics have long hired Spanish language translators.


A Team Incentive:
How It Works

Molina Healthcare, which originally operated clinics for Fairfax County’s Community Health Center Network, paid all members of the clinic staff a salary-percentage bonus for meeting care targets aimed at disparities reduction in cervical cancer screening, blood pressure control, and diabetes control. Physicians and within-clinic specialists treat patients; referral specialists make sure patients see in-house specialists as soon as possible; enrollment staff members help patients sign up for care; and the county public health liaison ensures patients have access to other County resources such as food stamps.

“The staff got into RCA big time. They learned things from each other. The conversation during the RCA revealed how closely all of the staff members watch over and care for their patients.” 

–Len M. Nichols, PhD

Project Director

Learn More 

Patient participants

Hispanic and non-Hispanic CHCN patients with diabetes or hypertension, or who are good candidates for cervical cancer screening. 

Intervention team

Each clinic intervention team includes primary care and specialist physicians; nurses; one county public health nurse liaison, who links patients to WIC, vision clinic, speech and hearing, or other Health Department services; one to two county referral specialists, who connect patients to needed specialty care (cardiology, physical therapy, etc.) and community resources (food banks, housing assistance, etc.), and human service enrollment staff members responsible for CHCN intake and who can also process an application for Medicaid or food stamps.

Payment incentive under Molina

Molina, the first clinic operator, awarded all members of the care team a bonus—a percentage of each staff member’s base pay—for meeting quality care and productivity target measures. Molina also incorporated relative value units (RVUs) in calculating the payment incentive. RVUs assign value to a specific procedure or activity. Activities that promote disparities reduction for target conditions—for example, identifying a patient in need of cervical cancer screening and getting her screened the same day—were assigned a higher value.

The county and Molina agreed on a maximum budget each year. Molina decided how and where to spend the money in running the clinics and paying care teams. The payment incentive was incorporated into Molina’s clinical care team compensation scheme and was budget-neutral.

Tools for Success

Payment incentive

The clinical team earns a bonus based on quality care, productivity, and disparities reduction measures.

Root cause analysis (RCA)

All clinic staff members collaborate to discuss and pinpoint potential causes of observed disparities. Patient focus groups then explore the issues raised—for example, the clinics have long hired Spanish language translators, but translators for other languages are harder to access.

Performance data

Patient data are stratified by ethnic group (using electronic health records), allowing for disparities reduction analysis.

Patient surveys

Pre- and post-intervention surveys will detail patient experience and behavioral/health self-management.

Other patient resources

Co-pay coupons are available to patients who attend certain follow-up visits.

Finding Answers: Solving Disparities Through Payment and Delivery System Reform is a national program funded by the Robert Wood Johnson Foundation with technical assistance and direction provided by the University of Chicago. Finding Answers was created to discover and disseminate practical ways to achieve health equity and is currently focused on discovering how healthcare payment and delivery systems can be redesigned to reduce and eliminate health care disparities. Its current work includes three pilot projects involving health systems and payers partnering to improve health equity.

More information about the Finding Answers payment and delivery system reform initiative is available at: