Medicine & Health

How to pay for equitable outcomes

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Collecting the right data

Providers have not previously been incentivized to collect data on patients’ race, ethnicity and other personal information, said Pham, the previous CMMI chief who currently serves as president and CEO of the Institute for Exceptional Care, which works to improve care for people with intellectual and developmental disabilities.

Payers, meanwhile, have long argued that they rely on providers for patient information. Thirty-eight percent of health systems said inconsistent data collection represented a major barrier to implementing equity-focused measures, according to the IHI report. To incorporate equity into value-based care models, providers need to know much more about their patients.

Groups like the National Quality Forum have developed roadmaps for “disparity sensitive measures” that providers can use. CMS approved new medical codes this year for tracking food insecurity, housing instability and homelessness, allowing researchers to start compiling data on the costs the social factors inflict on the healthcare industry and patient outcomes.

Payers like Kaiser Permanente have also invested in tools such as Now Pow that clinicians can use to collect social determinants data. In September, Unite Us, a tech company focused on measuring health outcomes, paid an undisclosed sum to purchase Now Pow, making it the leading integrated health and social care network provider in the nascent market.

In June, UnitedHealth Group launched an in-house predictive analytics system that uses artificial intelligence to screen and predict employer customers’ social needs. By assigning each member a personalized health score, UnitedHealth aims connect patients with community resources, lower its healthcare spend and better understand the social needs of commercial enrollees, who have not traditionally been part of health equity conversations, the company said.

“You should really learn about who you’re serving, and you should also recognize your place in the community,” Pham said. “If you’re a well-resourced provider, you should take a step back maybe and understand that payers may redirect some resources elsewhere. If you know you’re a provider serving a lot of impoverished patients, I would start making a wish list of the types of help I would want from a payer.”

This year, CMS has also started comparing hospitals with similar numbers of dual-eligibles in the Hospital Readmissions Reduction Program to better account for the heightened patient risk at safety-net hospitals compared with health systems operating in primarily white, affluent communities.

Minnesota has adopted a statewide system that pays providers for reporting and performance on measures that are linked with social needs screenings and health disparities. Rhode Island’s Medicaid agency has likewise adopted a similar program, along with some other states’ Medicaid departments.

“I think payers are incented to create better outcomes because if you need more expensive care less, then they also get the benefit,” IHI’s Mate said. “They’re noticing that a lot of what costs them lots of money is inequities.”

CMS needs to report on its own progress in bridging healthcare inequities, Mate added.

But it is critical for payers to avoid pathologizing race, and remember that data on an individual’s identity is not a substitute for the lived experience of racism, said Dr. Joshua Liao, medical director of payment strategy at UW Medicine in Washington state. Specialists must also be engaged in collecting this data since, in many instances, they serve as a patient’s primary point of contact, Liao said.

“Things like race identity, race centrality, ethnic identification, those things are going to be really important, because if we get the data and make the assumption that they then capture what we want, we may then kind of barrel forward,” said Liao, who also serves on HHS’ Physician-focused Payment Model Technical Advisory Committee, which is in the process of making recommendations to federal regulators about how to incorporate equity into value-based models. “I think we need to be cautious in certain aspects of social risks.”

Multipayer models created with both private plans and federal programs in mind help physicians ease into accepting risk, since they allow providers to align the incentives of multiple, larger patient populations and simplify the structure of their operations. It also eases the administrative burden on providers, particularly those with fewer resources, said Maryellen Guinan, principal policy analyst at America’s Essential Hospitals.

“We really need to level the playing field, and not create what, essentially right now, is a vicious cycle,” Guinan said. “Our members (safety-net hospitals) are the ones who are being innovative and forming initiatives to address social determinants of health. But at the same time, they’re being penalized by these measures that don’t incorporate all those factors. It’s really just taking resources away from the work they’re doing.”


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