Facts, Conclusions, and More Questions on the Road to Solving Disparities

By SCOTT COOK, PhD

We tested whether new payment mechanisms could be harnessed in health care delivery reform to reduce health and health care disparities. Here’s what we found.

First, there were facts that couldn’t be ignored:

#1: Children in rural Oregon on Medicaid suffered more health-related dental challenges compared to children with private insurance, including the pain, systemic health problems and disruptions to education that come with them. Advantage Dental, the state’s largest provider of Medicaid services, was determined to do something about it.

#2: New mothers on Medicaid in a New York City hospital were less likely to have a postpartum care visit compared to privately insured women. As a result, they missed assessments and screenings for a number of health conditions, some of which can lead to chronic health problems throughout their lives. For many women, the postpartum visit is one of the few chances to engage them in ongoing health care. The providers and care teams at the Icahn School of Medicine and the Mount Sinai Health System wanted to find out what it takes to increase postpartum visit rates.

#3: In Fairfax County, Virginia, multi-racial and multi-ethnic populations being served in three County-funded safety-net clinics were less likely to receive the typical high-quality care provided for hypertension, diabetes, and cervical cancer screening when compared to their Hispanic counterparts. The providers and teams at the Community Health Care Network stepped forward to address the issue.

Beginning where the Roadmap ends

At Finding Answers: Solving Disparities Through Payment and Delivery System Reform, a national program of the Robert Wood Johnson Foundation, we have known the best practices for reducing and eliminating disparities like these for a while now. That knowledge was derived from the work of 33 other health care organizations around the country that had also identified disparities in their own patient populations. We partnered with them between 2006 and 2013 to evaluate and collect detailed implementation data in over 200 clinical settings on their novel solutions to the health and health care disparities that their patients faced. We also conducted 13 systematic reviews of the disparities intervention literature.

We integrated all of this knowledge into the Roadmap to Reduce Disparities (Roadmap). The Roadmap guides organizations through the processes of identifying and reducing disparities in their own patient populations. We have also provided technical assistance to health care organizations that followed the Roadmap, partnering with them as they tackled subsequent challenges and successes.

Reducing and eliminating health and healthcare disparities is possible. We know what to do, but the path laid out by the Roadmap requires time and resources. Unfortunately, dedicated care teams like those at Advantage Dental, the Icahn School of Medicine and the Mount Sinai Health System, and the Community Health Care Network who are motivated to eliminate disparities are operating within a national system that does not provide the business incentives necessary for providers to devote the time and resources required. This is why we selected three investigators four years ago — to help us chart a new course in developing the business case. We took advantage of the nation’s efforts to move away from fee-for-service to newer financial models that incentivize improving quality of care while also reducing costs.

We asked these organizations to partner with at least one payer to design and implement an integrated model of payment and health care delivery reform that would make going down the path of the Roadmap a bit easier. We hoped that their new integrated models would help us learn best practices for similar efforts in the future. The teams at these organizations rose to the challenge because of their dedication to their patient populations and to reducing the pain, suffering, and early deaths that often result from the disparities they face. You can learn about their unique integrated payment and health care delivery reform models here.

Key lessons learned

In a nutshell, here are a few lessons learned from our recent grantees’ experiences:

• Health system leaders and payers are key to changing how vulnerable groups are cared for.“But it takes prioritization, work, readjustment, and persistence,” says Finding Answers Director Marshall Chin, MD, MPH. “Giving these projects authority and staying power requires commitment from the C-suite. It means restructuring payment to support and incentivize the reduction of disparities. Utilizing value-based payment reforms to give organizations the resources and incentives they need to address disparities is a critical next step.”
• Team-level incentives hold promise. They encourage integrated care management as team members strive toward a common goal.
• Payers should partner closely with front line providers and other care delivery staff members when designing a financial incentive program. Designing an effective financial incentive program is a multifaceted, complex endeavor and no single organization or group has all the information needed for success.
• Sometimes the most effective use of funds is to allow the flexibility needed to redesign the care delivery system to address health and health care disparities. Mount Sinai Health System increased timely postpartum visits among women on Healthfirst Medicaid plans from 58% to 74% largely through a cost-sharing arrangement with Healthfirst that allowed them to hire a social worker and patient navigator. Capitated models with global budgets provided the flexibility needed for Advantage Dental and the Fairfax County Virginia Community Health Care Network to redesign their delivery models to focus on goals of improving quality, reducing costs, and reducing disparities.
• Providers are motivated to reduce disparities, once they find out they exist. New financial models might make it possible to reduce or eliminate disparities, especially when aligned with state Medicaid programs and federal policies.

The next questions

After three years of implementation, analysis, and adjustments, Advantage Dental, Icahn, and the Community Health Care Network provided insights to make moving down the path laid out by the Roadmap easier. While there is still more work to be done to discover best practices and recommendations for integrating payment and health care delivery reform to address disparities, we are excited about what we’ve learned so far. You can see more of our top-level findings here.

Over the next few months, we will update Finding Answers’ resources and tools to incorporate the knowledge gained from their experiences. Please check back to our blog at www.SolvingDisparities.org and follow us on Twitter @FndgAnswers for further developments as we continue down the path.

Scott Cook, PhD, is deputy director of the Robert Wood Johnson Foundation program Finding Answers: Solving Disparities Through Payment and Delivery System Reform, and a Quality Improvement and Clinical Transformation Strategist in the Department of Diversity, Inclusion and Equity at the University of Chicago Medical Center.

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