In the wake of the pandemic and racial justice movement of 2020, many health systems have created positions or task forces related to health equity. But will this work be sustained and actually decrease the disturbing disparities in clinical outcomes?
Some health system executives are recognizing that paying lip service to equity is not good enough. “We are putting our money where our mouth is,” said Kevin Mahoney, CEO of the University of Pennsylvania Health System, speaking last October during a webinar put on by the Philadelphia-based university. “We built it into the pay of the top 600 executives at Penn Medicine. Our executive pay is tied to reducing maternal morbidity and mortality among Black and Brown populations and increasing colorectal screening among our Black population. If we don’t make those improvements, we don’t get paid. We know that incentives work. We are tired of talking about it. We are going to take dramatic action, but doing it by impacting the higher-paid people’s paycheck. I wish it didn’t have to come to that, but that is the way we know we can move the needle. I’ll be happy to report next year — I know we’ll have achieved these goals because we built them in.”
Efforts like the one announced by Mahoney are still the exception to the rule. Marshall H. Chin, M.D., associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, says there has been some fair criticism of healthcare provider organizations, payers and the government that they have done work to document disparities but very little to intervene to reduce disparities. (Chin co-chaired the National Quality Forum Disparities Standing Committee that recommended how to achieve health equity through performance measurement and payment reform to the Centers for Medicare and Medicaid Services.)
Provider organizations may do something like cultural competency training, Chin says. “These things help, but it is different than saying we are going to reduce our differences in outcomes between African-Americans and Whites in blood pressure, and then thinking about a very sophisticated, very explicit process to do that,” he explains. “You determine what your goal is, do a root cause analysis to determine why there are differences, and then design the interventions to specifically address the drivers of those disparities and create an environment that enables physicians to do the right thing. That includes payments to incentivize these types of care transformations. People can do it out of the goodness of their heart in the short term, but for something to be sustainable — and that’s the goal here — there’s got to be a business case. And right now, there are not nearly enough examples from the perspective of individual healthcare organizations.”
Being transparent about equity metrics
She says one silver lining of the pandemic is that it affects everyone. “It is not just about a social determinant of health, like lack of housing. If we don’t fix it, we’re all impacted, and none of us can move forward. So it really forced us to address why our healthcare system is not working for everyone,” she explains.
When the pandemic hit, health systems such as Mass General Brigham (part of Mass General Hospital) that had already begun work on equity and health disparities were better able to re-evaluate what they were doing than ones that haven’t put much effort into this yet, Tan-McGrory says. “We have over 10 years of stratifying our data by race, ethnicity, and language. So very quickly, we were able to leverage that to look and see who’s coming into our hospitals. And we did see over 50 percent of our patients are coming from diverse immigrant communities and needed interpreters. But even as well set up as our system was, there were still a lot of gaps and lessons learned. There’s nothing that brings home the importance of integrating interpreters into our systems than having half of your floor needing an interpreter. The urgency didn’t have to be explained.”
Mass General Brigham created the Disparities Solutions Center to help other healthcare organizations that want to address disparities. “When we started, we were probably one of the few centers that focused on the intersection of quality and disparities and how healthcare organizations can address this, and then expand to a bigger scope to get leadership buy-in,” she says. “You have to consider social determinants of health, the historical events that have preceded us that have led to this distrust in our community, and opening the walls of our institutions to include community health.”
Mass General Brigham has been doing this work for more than 10 years and it has made its results publicly available. Some hospitals say they’re committed, but have not made the effort yet to collect accurate racial and ethnic data from patients or are reluctant to publicly share their dashboards, Tan-McGrory says. “We can do a lot of measurement, but eventually you have to do something about it, right? And doing something about it requires money and resources. The last year has provided that catalyst for boards to realize that they have to put some money into this — like serious money.”
Equity efforts in Medicaid managed care
Shilpa Patel, Ph.D., the associate director for health equity at the Center for Health Care Strategies (CHCS), leads multiple projects that support states and healthcare systems to advance health equity for people served by Medicaid. She notes that Medicaid agencies are increasingly focusing more on equity and operationalizing their commitment and priority to equity in different ways, including taking value-based purchasing approaches. “We’re seeing that state Medicaid agencies and their partners, Medicaid managed care organizations (MCOs), are working with provider groups to reduce disparities for the Medicaid members,” she says.
CHCS’ Advancing Health Equity initiative is working with Medicaid agencies, MCOs and provider groups to develop and implement care delivery transformations and payment approaches. Patel says these efforts are driven by data at the plan and state level, so organizations must use the data they have to identify disparities as well as mechanisms to bolster their capacity to either collect and report on the data.
“We’re also seeing some stakeholders using contracts between the health plans and providers to either require or financially incentivize measurement and tracking disparities, and as part of that, helping them afford the infrastructure required to monitor and track reductions,” Patel adds. “The COVID pandemic has really galvanized the need to stratify data in order to tailor your efforts. So hopefully we can use some of that momentum more broadly as part of these Medicaid innovations, and also use either existing or planned value-based contractual requirements as a starting point.”
States, payers and provider organizations are assessing how progress toward an equity goal will be measured through performance measures, she says. For instance, Oregon has used a metric around emergency department utilization intentionally focused on reducing disparities for people experiencing mental illness. Michigan has included in its Medicaid managed care contract initiatives to improve low-birthweight babies and have incentivized this through their contracts. “They also have an Index of Disparity that they’re using for their plans to identify and track their reduction in disparities,” she notes.
If state governments are making some progress, Chin says that frankly, the federal government has done relatively little so far. “They have talked about it in some of the innovation grants such as Accountable Health Communities,” he says, “but with all the interest in alternative payment models, they are at very early stages of thinking about value-based payment with an equity lens.”
Chin says it seems that sometimes people use a form of “magical thinking” to believe that value-based payment and alternative payment programs are going to fix everything. “Well, not if they are not intentionally designed,” he says. “There are a lot of ways to get around addressing equity issues — hence the virtue of designing the incentives to do the right thing. The vast majority of providers in healthcare would love to do the right thing, but they’re working under rules of the game which don’t enable them to do the right thing in the long term.”
