The idea of health equity has existed for some time, but the fact of patient care organization leaders, including the leaders of accountable care organizations (ACOs), moving to incorporate it into their strategic directions, is quite recent. Yet that relatively recent phenomenon is quickly gaining steam, as the presentations and discussion involved in a webinar that took place on Tuesday, February 15 over Zoom, made clear. NAACOS, the Washington, D.C.-based National Association of ACOs, sponsored the webinar, entitled “How ACOs Are Addressing Health Equity: Insights from Innovators.” The moderator of the webinar was Jennifer Gasperini, NAACOS’s director of regulatory and quality affairs; and the presenters/discussants were Alvia Siddiqi, M.D., vice president of population health at the 26-hospital Advocate Aurora Health, based in Milwaukee, Wis., and the Chicago suburb of Downers Grove, Ill.; Kisha Davis, M.D., M.P.H., vice president of health equity, at the Washington, D.C.-based Aledade consulting firm, which advises medical groups and other organizations participating in value-based contracting, and who is also and vice chair of MACPAC, the Medicaid and CHIP Payment and Access Commission; and Robert Fields, M.D., M.H.A., executive vice president and chief population health officer at the eight-hospital, New York City-based Mount Sinai Health System.
After being introduced by Gasperini, Drs. Siddiqi, Davis, and Fields each presented regarding what their organizations are doing in the health equity sphere, and then Gasperini moderated a discussion among the participants.
Dr. Siddiqi drilled down several levels on the very practical steps that she and her colleagues have been focusing on, around health equity, focusing specifically in her presentation on hypertension among Black residents in the Milwaukee and Chicago metropolitan areas. She cited the fact that, among Black and Latinx residents in target zip codes identified as vulnerable, 48.5 percent of Black residents have uncontrolled hypertension, while 24.4 percent of Hispanic residents are living with uncontrolled hypertension.
“We’re using our population health index, which looks at population health measures, as we work to stratify data,” Siddiqi said. “We’ve been looking at race and ethnicity statistics for various measures: breast cancer screening, hypertension control, HPV vaccination, influenza vaccination, and well-child visits. And what we found is that we didn’t see much discrepancy in terms of breast cancer screening, but did, around hypertension control, so we began focusing” strongly on that issue. “We’re trying to impact 1,000 patients with uncontrolled hypertension this year and 2,000 next year,” she said. And in that regard, she said, she and her colleagues have pulled professionals from numerous disciplines into the Health Equity Hypertension Task Force created last year at Advocate Aurora, including from healthcare IT, community health, medical groups, patient service area operations, enterprise population health, and research, all working as a team to prioritize achieving improved outcomes around uncontrolled hypertension in Black and Latinx communities in Milwaukee and Chicago. It’s clear that uncontrolled hypertension is a leading indicator of poor health status, she added, with one in two Americans living with hypertension, while only one in four who have it have their hypertension controlled, while among Black Americans, that figure is only one in five. And in order to succeed, she said, “We have to work with communities, not just internally” inside the Advocate Aurora system. “Our primary aim is closing the gap by 10-20 points within the next year or so,” using eight “driver teams”—remote monitoring, social determinants of health, community health, patient education, a disparity dashboard team, a care management pod, and a primary care/nursing intervention and visit model-based team. She reported that leaders at Advocate Trinity Hospital on the South Side of Chicago have been working with the Medicaid population on the South Side; all of these communities, she said, are ones which are fertile for those healthcare leaders working to enhance health equity through addressing a key population health issue such as uncontrolled hypertension.
Aledade’s multi-pronged outreach to FQHCs and communities of color
Dr. Davis began her portion of the program by noting that Aledade, which was founded in 2014, is currently working with 35 ACOs participating in the Medicare Shared Savings Program (MSSP), as well as 55 other value-based partnerships. Meanwhile, she said, “Our emphasis on health equity is relatively new; it was kicked off in 2021.” In that context, she said, “We really seek out minority and vulnerable communities and the doctors who serve them. They have traditionally been left out of ACO work. We’re seeking them out. We want our practices to serve marginalized communities and want them to become culturally competent in doing so.”
And in that regard, Davis said, she and her colleagues at Aledade have been focusing on three key strategies: working with Medicaid populations, engaging community health centers (federally qualified health centers, or FQHCs), and attacking health disparities. She showed a slide entitled “Aledade’s Center for Health Equity adheres to three key strategies,” which stated those strategies (Medicaid, community health center engagement and practice integration, and health disparities reduction), with the following bullet points:
Ø Ensure all with a trusted PCP relationship
Ø Success directly impacts communities and bolsters success
Ø Drive health outcomes throughout the full lifespan with intense focus on access prevention, care transitions, risk and prioritization (esp. with BH & SDOH)
Ø Target hypertension control and disparity, especially among Black patients (2022)
Ø Four segments of action: patient-facing, provider-facing, technology-enabled interventions, and community and caregiver supports
Ø Flagship multi-state community health center-only ACO in 2021
Ø Bolster capacities of PCP practices caring for predominantly minority or vulnerable communities
With regard to community health centers and FQHCs, Davis noted that “Almost half of our Black and Latinx populations are served by community health centers and FQHCs,” which means that addressing health equity must necessarily involve engagement with those entities. Indeed, she said, “Community health centers are very well-suited for engaging in value-based care delivery and work. We’re helping them to get credit for the work they’re doing. In 2022, we’re focused on building that strong enablement and tech platform.” What’s more, she said, “We have 104,000 total lives under management under Medicaid,” and, among that group, “We’ve lowered the total cost of care for Medicaid patients by 4-10 percent,” a figure made all the more impressive by the fact that “Medicaid patients are assigned.” And in that regard, sometimes the very most practical steps can have a major impact. For example, she said, many Medicaid recipients are assigned to primary care physicians who are geographically distant from them or difficult to reach. Indeed, when a simple adjustment is made—connecting Medicaid patients to easily accessible PCPs, that step leads to improved outcomes. What’s more, she said, “At the core of our Medicaid strategy is creating that strong patient-PCP relationship.”
And, Davis said, “Hypertension is the place to focus. You’re hearing so much about that, because hypertension is the single most effective way to save lives. If we can solve the hypertension disparity, we’ll save money and save lives. There is nothing more important. At Aledade, we started with metrics and dashboarding; we can’t see the disparity if we don’t look for it. And creating some awareness.”
Another key strategy that Davis cited at Aledade is the organization’s initiative to recruit physicians of color to serve in underserved, POC-majority-population areas, as well as their effort to lend practical support to ACOs serving patients in those areas. She emphasized that, “Given a little bit of extra support, they can perform as well as everybody else. Several practices told us that had we not come along, they probably would have folded within a year. One doc said, if you hadn’t come along and I had had to close, I don’t know what my patients would have done. They would probably have died,” she said. And, she added, Aledade is helping to directly recruit physicians of color, while in residency, to serve communities in need.
In New York City, leveraging data to support health equity efforts
Dr. Fields shared that he and other leaders at Mount Sinai Health System, which encompasses a clinically integrated network of 4,000 physicians, three-quarters of whom are salaried, and which is caring for a half-million lives under value-based contracts, have been leveraging data analytics in order to move forward on health equity.
To illustrate the situation, Fields said, “Like many other organizations, we started with a pretty significant problem around data: 38 percent of our attributed lives had blanks in them” when it came to designation of race in the Epic electronic health record (EHR) used by the organization.
Meanwhile, Fields told the audience, “There is no path to success in value-based care without achieving equity: 52 percent of all attributed lives identify as racial or ethnic minorities, and the actual number is probably higher, per the blanks in the race field in Epic.” And, he said, “One specific way in which we’ve used this data is in our condition management program.” He explained that, in the traditional care model, “Not much happens between visits” that patients have with their primary care physicians; but that in the condition management model that he and his colleagues have developed, a lot is happening. Fields and his colleagues at Mount Sinai have created a model in which a core team of clinical pharmacists works with physicians “in the way that physician assistants and nurse practitioners traditionally work. They can prescribe; they know the medications well” that the patients are on, and “can address cost issues and prior-condition issues,” which allows them to address clinical issues from an equity perspective.
Meanwhile, Fields said, one incredibly important element in applying an equity lens to care management is to ensure that any care management program not involve personal disincentives for patients. “Any devices have to be easy to use; and many of our patients face barriers around available broadband or Wi-Fi.” As a result, the Mount Sinai team members are making use of a portable cellular data hub, which automatically transfers data from the tech-enabled patient monitoring devices. What’s been excellent, he reported, is that “Disenrollment rates” from the care management program “have been in the very low single digits, which is very unusual; and a lot of that is due to the simplicity and access issues: patients don’t have to struggle with the technology. So that’s been very helpful to us in terms of crossing that digital divide and reaching vulnerable patients.”
And with regard to that, Fields said, “I strongly encourage programs to consider low-tech design, which was critical to our success. Considering the digital divide, the low-tech approach was important. Second, you have to be intentional about equity, it doesn’t happen by accident. And a lot of this is about measurement. If you don’t measure, you’ll miss folks. And do registries, along racial and ethnic lines, to reach the patients.”