Many health systems have recently announced health equity initiatives. But Healthfirst, a New York-based nonprofit health plan, has been working for several years to build partnerships with healthcare providers and community-based organizations to establish an evidence-based approach to closing health equity gaps among members.
Healthfirst has released a series of case studies about topics such as asthma, hypertension, senior care, maternal health, and HIV. In an interview with Healthcare Innovation, Healthfirst executives discussed some best practices shown to reduce disparities in the healthcare system.
Healthfirst was established in 1993 by 15 New York hospitals. It serves 1.7 million members in New York City and on Long Island, as well as in Westchester, Orange, and Sullivan counties. Over 1.2 million members are in the Medicaid program.
The first use case the executives discussed involved a partnership with Mount Sinai Health System on an educational intervention and payment redesign program, which was shown to improve timely access to healthcare services and community resources for low-income, high-risk mothers.
“We were approached by Mount Sinai in a very prescient way to discover whether we could know more together than we could know apart — a managed care organization and a healthcare delivery system,” said Susan Beane, M.D., Healthfirst’s executive medical director.
In their initial look at data on postpartum events for women, they saw some indications of disparities. “It led us to be extremely interested in their evidence-based intervention,” Beane said, “to see whether we could use it to change the trajectory for these women who represented communities living with various kinds of hardships, communities of color.”
Rashi Kumar, Healthfirst’s director of research and policy, said it was exciting to be able to pair the data of the managed care plan with the data that Mount Sinai collects from EHR systems.
“You're better able to see all that's going on around the patient. When we looked for the disparities at the outset, when we're designing the care model, we found that women of color and women with high-risk clinical conditions were way less likely to be able to return for care after their delivery,” Kumar explained. “That gave us the premise to build this care model to advance the evidence that Dr. Elizabeth Howell and her team had already built around maternal health and care transitions, and to implement it. She helped us build the model. We combined our data sources to understand how women were accessing care after their delivery. With these data sources combined, we were able to actually advance the evidence base, and share what we've learned together.”
I asked whether this work was scalable and could be transferred to other settings as well.
“When we were thinking about translating that study into practice, we thought about all the stakeholders out there who might be well-suited to help us run and evolve this model,” Kumar responded. “We became very interested in the idea of community organizations that are not sitting on the hospital side of the table, but sitting more of the member/patient/client side of the table. We wanted to have them help us think about how this model could be run, and not just in one site, but in many places where there is need. That is one arena that we've been very thoroughly investigating.”
Another impact of the study was at the policy level, Beane added. “It is actually one of the few studies that has shown this kind of positive change for women of color in a community like Harlem. Our lessons learned were actually adopted by the state in terms of policy going forward on postpartum care. That speaks to why we, as a managed care company, invest in this kind of work.”
Another study involved a partnership with NYU-CUNY Prevention Research Center funded by the CDC. Its researchers had analyzed public health data and found that South Asians were at much higher risk for cardiovascular disease and death than the general population and that there was a scarcity of interventions designed to help them decrease their risk.
“They worked with us to identify community practices that were serving South Asians and to do a needs assessment of the practices to make sure that it was the right fit,” Kumar said. “We ended up finding small storefront practices, mostly in Brooklyn, Queens, and the Bronx, that were serving immigrant communities and South Asian American communities.” NYU first worked with them to help them understand how to implement evidence-based practices for hypertension with a lot of fidelity, using their electronic health records. “Once they did that, they added a community health worker who did lifestyle coaching with their patients. And through this study, we actually showed that using the community health worker makes a huge difference to hypertension control.”
More recently, Healthfirst has begun working with NYU again, on another study looking at African-Americans in New York City who have high blood pressure, said Tom Wang, manager of research and evaluation. “This is where bringing together the resources of both the managed care organization and hospital has been really helpful. We've seen that there are a large percentage of members who are not diagnosed with hypertension, according to the records that NYU has, but show up in our claims with a diagnosis of hypertension,” he said. “For the physicians, you can't necessarily address the issue if you aren't aware that there's a problem. We want to see if we could identify the reasons why there might be that discrepancy in the diagnoses and obviously, be able to address these needs, to provide more equitable care and close gaps.”
Most of the Healthfirst case studies involve the use of community health workers or navigators or care transition specialists. “From these studies we are learning more about the protocols for these community health workers and what they do on a daily basis,” Kumar said. “How do we embed them into practices so that they're acceptable to practices and acceptable to the members? It's really about how you use them for attaining optimal medical outcomes.”
“Perhaps our greatest lesson learned is that there's an opportunity to fill not so much care gaps, but gaps in caring and access, by using these organizations that have dedicated themselves to serving communities,” Beane said. “You know, for years and years, they have what we call a secret sauce that they implement with integrity, and each one is a little different. And all of it is built around what the communities need. I think from that first study with Mount Sinai through the NYU study, we have pretty much always thought of community health workers as critical success factors for any of this work.”
Another lesson learned in doing this work, Beane said, is that it takes urgency combined with patience. “We are attempting to navigate even though the roadmaps have not been created yet. We are trying to open up new pathways of understanding that bring us closer to our provider community, and that takes a lot of patience and rigor, but at the same time, you have to have urgency.”
I mentioned that CMS executives have said they want to put equity at the center of everything they're doing with payment models going forward. I asked if the Healthfirst executives had any suggestions or a wish list for CMS.
“We're beginning to look at some care models around children and families,” Beane said. “That an area where return on investment becomes very difficult to show, although, there are examples of states that have invested in the health of children, and New York State is joining those ranks. The investment is early, but the return is ongoing. I do think that if there were more opportunities for us to not have to worry so much about return on investment in the first six years of life, we could do more for those children that would yield this ongoing benefit to society and to the healthcare delivery system later on.”
To help others starting out on this journey, Healthfirst has produced a few tips for closing care gaps based on their experience, and the initials of all of them spell out ADVANCE:
- Available to all people, with equal opportunity to access quality care
- Data-informed to close gaps in care and support care continuity and coordination
- Value-driven through hospital, physician, and insurer alignment around optimal health outcomes
- Accessible when and where help is needed, so everyone is surrounded with opportunities for healthcare access and continuous insurance with no gaps
- Nurturing and human-centered so it is easy to engage with and navigate
- Community-based with strong ties to services and resources that promote whole-person care and address social determinants of health
- Evidence-based with the best available clinical expertise and research guiding every treatment plan, care decision, and public-health intervention
