Payment Reform Called ‘Necessary but Insufficient’ to Advance Health Equity

May 16, 2022
During Primary Care Collaborative webinar, stakeholders assert that infrastructure capacity building, practice level transformation, payment transformation, and policy transformation are all crucial building blocks

During a May 12 webinar put on by the Primary Care Collaborative, stakeholders discussed why value-based care efforts to support practices in screening for social determinants are just the first steps in transforming care.

As payers and large integrated health systems seek to support providers in incorporating data on social determinants of health, and to enable providers to help their patients meet their social needs in primary care, a wide variety of approaches are being tried, and researchers are assessing the impact.

Rishi Manchanda, M.D., is CEO of HealthBegins, a firm that helps healthcare systems advance health equity specifically by addressing the social and the structural drivers of health equity.

During the Primary Care Collaborative webinar, he said that if we as a society are going to equip primary care with the resources to prevent harms, then healthcare providers need to understand the social needs of their patients. “We need to think about how primary care can play its part in being able to contribute to community-level efforts to address the social determinants of health,” Manchanda said, “and, then support activities to dismantle forms of structural violence that create those social arrangements in the first place.” He stressed that thinking about those social needs is not a side question. “It is fundamentally essential to what primary care is all about. What we've been doing is thinking about how to take that broad conceptual framing and apply it concretely into steps that primary care practices can take to advance racial equity. And a major step in that process is to understand not just how to collect information on social needs, but then to analyze the social needs to better understand the patterns of inequity that manifest in the lives of our patients that can help us to do more healing and to prevent more harm.”

Kameron Matthews, M.D., is a family physician and chief health officer for Cityblock Health, a value-based provider focused on Medicaid and dual-eligible communities in five U.S. markets.

She spoke about the approach that Cityblock takes. “Before we start any kind of conversation around your medical concerns as a patient of mine, I need that trust, I need that engagement, I need to understand the community that you're in. And we need to be customizing our partnerships, our technology, even our services, to meet those needs,” She added that much of what they do is try to be as interdisciplinary as possible, not just primary care and behavioral health, but bringing community-based organizations to the table as well, “so that we can be addressing food insecurity or homelessness right at the table, alongside behavioral health concerns. They're all equally as impactful on that patient's outcomes and on that patient's well-being.”

Cityblock has established several innovations such as an ED-at-Home program where they are sending EMTs into the homes instead of having their patients go into emergency departments. “We are working on having the services that are really ingrained in the community, and even meeting some of our patients on foot, at park benches even. None of that is easily possible or at all under a different financial model,” Matthews said.

HealthBegins’ Manchanda said that in terms of how to insert equity into value-based payment reform, he recommends using the concept of place as a way to start to understand your data and resources and then align your strategy.

He asked to what extent payers are able to support practices and not just provide incentives to collect social needs data? If you're already underpaying for primary care, and you provide just a little bit of incentive to screen for social needs, that's not going to be enough to incentivize fundamental changes in behavior, he added. But there are mechanisms by which plans can actually take the incredible data that they have and start to understand the inequities in maternal mortality, inequities in diabetes outcomes, inequities in access to post-hospitalization discharge care,” he explained. “These inequities, including specific racial inequities, can then be analyzed by place. To what extent do these inequities vary by Census tract? If they do vary, they are more likely to have social structural drivers. To what extent can you then leverage area-based social risk data to provide the prospective, upfront payments to allow practices to start to align their work to address these inequities at the level of the practices?”

Manchanda added that “even while the payment reform conversation continues to play out, it underscores the point that payment reform is necessary but insufficient; it speaks to the fact that infrastructure capacity, practice level transformation, payment transformation, and policy transformation all have to be operating at the same time. And that comes both from the evidence base that's being codified in the research, but it's also from the evidence that's being generated every day by those who are on the front lines of providing and receiving technical assistance.”

HealthBegins has been working with health plans on how the concept of place can be helpful by identifying health equity improvement zones to start thinking about how to apply data analysis, identify the inequities, organize resources by place and then engage providers, provide the prospective payments and support social service providers as well start thinking about how to address inequities that are defined by place and not by payer type or by payer specifically.

Laura Gottlieb, M.D., is a professor of Family and Community Medicine at UCSF in San Francisco. She serves as co-director of SIREN (Social Interventions Research and Evaluation Network), which is based at UCSF, but is a national initiative to improve the synthesis and dissemination of the evidence that is accruing at the intersection of social and medical care delivery.

She began saying kudos to Cityblock’s Matthews. “The work that you are doing is so exciting, and I hope it will inspire lots of other people to do things differently,” she said. Gottlieb emphasized, however, that on the payment side, Cityblock is pretty exceptional. “It has been more like 1,000 flowers blooming in terms of the different kinds of payment experiments that we're seeing in this field.” She said Medicaid waivers are an example of innovation around social determinants, but state Medicaid agencies also incorporate non-waiver-related strategies for addressing social determinants into their contracting and procurement, and those span the gamut.

Some of this involves screening at the patient level while other efforts involve doing something for communities.  Arizona, in some of its contracting, has a specific requirement around community-level investing, Gottlieb said. “It's all over the map. I would say that we're a long way from proven effectiveness. The reason we are seeing so much experimentation is because we don't 100 percent know what's going to work,” she said. “I would say it's incumbent on us to learn from those different payment models, and make sure that we're looking not only at what makes us do more and do differently, but really, what is achieving equity. The implicit assumption with all of this work was that we would advance equity, but in studying social determinants interventions, we haven't always consistently looked at equity as an outcome, and I think that that's the direction we need to go.”

Gottlieb noted that research has shown that the adoption of health-related social service payments hasn’t always been high. “It is hard to get people to change behaviors. An article by Amanda Brewster shows that it actually was practice innovation capacity, more than value-based payment opportunities, that led practices to do something different in primary care, so we have to think about all those other things. We need tech capacity, we need patient engagement structures, we need technical assistance, and we really need to support these systems around innovation.”

James Cruz, M.D., chief medical officer for Blue Shield of California’s Promise Health Plan, its Medicaid health plan, said that the transformation of Medicaid in California through CalAim serves as an important first step in terms of how to integrate patient social needs into primary care. The state Department of Health Care Services has issued specific codes that allow for the reimbursement of services addressing a medical member's social needs. “This is an important transformational mechanism that ensures that health plans and providers are able to take on that work,” he said. “Equally important, it provides an impactful funding stream for community-based organizations that provide those much-needed social services on a daily basis. These community-based organizations really serve as the cornerstone to address healthcare inequities experienced by communities of color and low-income Californians.”

Cruz said his plan has funded community health navigators and partnered those navigators in a variety of clinical settings, such as federally qualified health centers, and other community-based agencies so that they work with members, and with the providers. “They assist the member to identify resources to address their social needs. We also help them navigate through the healthcare system, to ensure they're able to access the clinical services that they need. From our standpoint, that's how we are beginning that process of integrating the social determinants of health into primary care.”

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