Increasing Health Equity to Reduce Disparities in Value-Based Care

The concept of health equity isn’t new—a search in PubMed from a decade ago will turn up 44 documents that mention the phrase—but over the past 5 or 6 years the realization that in the United States people of color experience very different health outcomes has exploded beyond the usual health policy circles.

With policy makers and health organizations reckoning even more intensely with health equity over the past 2 years, spurred by the pandemic and high-profile police shootings of Black Americans, the topic led off the 2022 V-BID Summit, hosted by the Center for Value-Based Insurance Design (V-BID) at the University of Michigan.

The 4 sessions were moderated by Clifford Goodman, PhD, senior vice president, Comparative Effectiveness Research, The Lewin Group.

The March 23 keynote panel, “Strategies to Reduce Health Care Disparities and Enhance Equity,” featured 2 leaders at the center of this work: Dora Hughes, MD, MPH, chief medical officer at the CMS Innovation Center at CMS; and Laurie Zephyrin, MD, MPH, MBA, vice president for Advancing Health Equity at the Commonwealth Fund.

Goodman asked Hughes and Zephyrin to give a high-level overview of where the United States stands now, asking, “Are we trending up, down? Are we treading water?”

The pandemic reversed progress in a number of ways, said Hughes, and is forcing the policy community to reexamine the issue of racial and ethnic health disparities, including understanding where new investment is needed to looking to see what has been successful and what still needs deeper work.

Last year, CMS released a “strategy refresh” to achieve a more equitable health system by 2030, with advancing health equity as 1 of 5 objectives, along with driving accountable care, supporting innovation, improving access by addressing affordability, and partnering to achieve system transformation.

The pandemic also “provided insight for those who may not have been aware that just how deep the problems are that we have to solve,” said Zephyrin, adding that while policy makers may want to ask questions aimed at determining the best solutions, “we can't wait….While we wait people are losing their lives and getting sicker when they shouldn't.”

Last year the Commonwealth Fund released a health equity scorecard examining how health systems are working in every state to achieve equitable health outcomes for people of color.

In all 50 states, even those where health systems are held in high regard, dispiriting gaps persist.

“The scorecard really shows that in state after state, people of color have worse experiences, worse outcomes, whether we look at outcomes, access, and quality,” Zephyrin said, calling these inequities “deeply entrenched and damaging.”

Goodman asked Hughes to elaborate on the new orientation at the CMS Innovation Center. The 10-year anniversary of the center, created as part of the Affordable Care Act, spurred the reexamination to see what was learned in the first decade and what needs to happen over the next 10 years in order to achieve equity.

The advancing health equity objective is embedded into thinking about revising or modifying existing payment models or creating new ones, she said, so as to understand how factors like recruitment, payment, and care delivery are geared towards promoting health equity.

Another focus is the recruitment of safety-net providers, including independent providers, federally qualified health centers, rural health clinics, or behavioral health clinics, “in part because we need to increase the number of beneficiaries from underserved populations who are participating in our models."

“The key to getting to more diverse beneficiaries is by increasing safety-net providers in our models,” Hughes said.

Evaluation, another focus area, means “being very deliberate from the very early stages when we're conceptualizing models” so that the questions are developed in such a way that the final result will be “robust.”

The fourth area focuses on strengthening the collection of demographic data and data on social determinants of heath, both for evaluation purposes and for design.

In addition, health equity is incorporated into the recently announced ACO Reach model. Health equity plans are required by participants, in order to describe how they intend to deliver care. There must be demographic data collection on those beneficiaries and providers who serve a a greater proportion of underserved beneficiaries will receive a payment adjustment.

Zephyrin reinforced the need for collecting better data in order to inform where opportunities are for intervention. Within her area at the Commonwealth Fund, there are 3 key focus areas— system, policy, and practice—aimed at reducing systemic racism in order to achieve equitable outcomes for people of color.

She cited, as one example, the work at Rush University Medical Center, which incorporated a health equity strategy in 2016, starting with calling out institutional racism and with senior leadership championing antiracism efforts.

Calling it a “semi-sensitive political question” Goodman asked her, “How optimistic are you these days about achieving the cultural change that would bring about a meaningful gain out of proposed policies? I mean, we can talk about policies all day long, but I might be a little concerned about our ability to pull off cultural change these days,” Goodman said.

Culture change is critical and the key to that is accountability, she noted.

“I am really a proponent of really helping to drive systems change and policy change and payment model to help provide that accountability that really creates that those incentives around culture change,” she said. And it requires a mix of constant conversation, and the willingness to tackle implicit or explicit inequities and biases, Zephyrin added.

Within the CMS Innovation Center, a team earlier this year looked at various value-based care payment models, such as for chronic kidney disease, a heart disease model, and a joint replacement model, to make sure that implicit bias had not inadvertently been incorporated into algorithms, Hughes said. The pilot project “did find areas that potentially we would want to be more attentive to moving forward,” she said.