Last year Blue Cross Blue Shield of Massachusetts became the first health plan in Massachusetts to announce it would incorporate equity measures into its contracts and payment programs with clinicians. Mark Friedberg, M.D., senior vice president, performance measurement and improvement at Blue Cross, recently gave a presentation hosted by the National Committee on Quality Assurance in which he described how Blue Cross is beginning to work with provider organizations to implement pay for equity.
Before describing the pay for equity work, Friedberg detailed how Blue Cross examined health disparities in its own data. The company reviewed 2019 administrative and health data from more than 1.3 million Massachusetts members and identified racial disparities that, in many cases, represent lower-quality care for Black, Asian, and Hispanic members on 48 industry-standard measures that Blue Cross tracks as part of its ongoing quality assurance operations. It has made that data publicly available on its website.
Friedberg described how Blue Cross is working to collect self-reported race and ethnicity data from members directly through its member portal and planned mailings. It also took advantage of the RAND Bayesian Improved Surname Geocoding (BISG) method, which is a commonly used approach when self-reported data are incomplete. Blue Cross notes that it is likely that analyses based on imputed data underestimate the true magnitude of inequities. For this reason, future versions of these analyses will transition from imputed data to member self-reported race and ethnicity data.
The next step is sharing race and ethnicity data with providers. “We are in an ongoing effort with our provider network in Massachusetts to exchange in a bidirectional fashion data on member race and ethnicity as well,” Friedberg said. “We're working with a state government task force as well to align on a vision and principles for data exchange.” The goal is to avoid fragmented and conflicting databases on individual member race and ethnicity between payers and providers, he added. “When we get down to things like paying for equity, we don't want to be in a position where when it comes time for settlement, we're arguing with providers over the race and ethnicity of individual members. That seems like it is kind of a wasteful activity, and we'd really like to be working from the same best understanding of race and ethnicity on both sides.”
He noted that data completeness and accuracy range widely on the provider side. Some providers have years of experience collecting race and ethnicity data and are using a data standard that's uniform throughout the organization. “Often it's large organizations that are on just one instance of an EHR,” he said, “but some providers are in very different positions. They might have multiple EHRs; they may never have done a formal assessment of the completeness or accuracy of the race and ethnicity data.”
Building on experience with alternative quality contracts
Friedberg said Blue Cross is able to begin work on pay for equity because it has a dozen years of experience with alternative quality contracts (AQCs), which he described as a mature, global budget, ACO-type payment model that their provider network is very familiar with. “We have an in-house quality improvement team called our network performance support team that has great relationships with counterparts throughout AQC provider groups. This really helps, I think, move into this new space.”
One way that Blue Cross is trying to tackle some of the inequities they saw in HEDIS measures is by fully incorporating equity into all parts of the AQC, Friedberg said He noted that previously a lot of focus has been on the payment side of the AQC. “I think that really does a disservice to two other really important pieces of the AQC, which are the data and support. And for equity, we're actually already fully engaged on data and support, even though the payment piece will not start even for the earliest providers until 2023. For data, we distributed confidential equity reports to all AQC providers in September of 2021, and that's been motivating and very guiding for the providers.”
The support area is where Blue Cross’ work with the Institute for Healthcare Improvement comes in. IHI has created an Equity Action Community with all 13 current AQC provider groups. “We also have health equity grants that are intended to help with some of the upfront costs of making investments in equity, such as improving capabilities within provider systems,” he said. “As far as I know, we're the first payer to really try to create pay-for-equity payments.”
Shannon Welch, M.P.H., IHI senior director, said one of the goals of the Equity Action Community is building the data infrastructure to support health equity. “We're not able to improve health equity if we do not have access to data that we can reliably stratify by race, ethnicity, language, and so on,” she said. “Having that information, we can identify opportunities to improve, and once we make an improvement, we can tell whether we've made a difference in equity gaps. We have expert faculty along with improvement advisors who will be supporting the AQC provider groups. We will be encouraging them to highlight what they are trying to accomplish in setting aims that are very time-specific and measurable.”
Unlike other pay-for-performance programs, Blue Cross wants to emphasize collaboration over competition between provider groups in this program. “This is a kind of big departure from the standard construction of a pay-for-performance program, both for providers and for payers,” Friedberg said. One way they are doing that, he said, is by moving away from cross-sectional grading-on-a-curve comparisons for setting payments. “The second is to actually explicitly incorporate a bonus payment to all groups when the overall market level inequities improved by a certain amount. That will directly incentivize the smaller groups who may have done something really remarkable to share whatever they learned with the larger groups, and then move the entire market. We want to maximize the likelihood of positive spillover effects for patients who are not our members.”
Likewise, he said, Blue Cross wants to harmonize whatever it does in pay for equity with what other payers are doing. “We are the first in our market to really be moving down this pathway, but there may be some possibilities that others will follow from our design, and we're trying to be as open and transparent about how we eventually stand this up as possible, so it makes it easier for others to harmonize with us,” Friedberg noted. “This is very important, because for providers to respond well to a new incentive, it's hard for them if they're dealing with multiple different programs that are broadly intended to achieve the same effect, but don't actually encourage the same kinds of investments. We do need to have some kind of convergence there so that providers can respond in the best possible manner.”
