Prioritizing equity in value-based care

As we move toward value-based care models, how do we prioritize patients that have historically been neglected in our health care system? In a recent article in Health Affairs, Harvard Medical Students Ayotomiwa Ojo and Parsa Erfani, and Harvard Medical School professor Dr. Neel Shah discuss how we value Black lives within value-based care.

Be intentional about reducing disparities

First, institutions that implement value-based models must be intentional in their goal of advancing equity. We must recognize the impact of structural racism on health disparities and medical care, and make sure that our models are explicitly designed to reduce these disparities. Otherwise, we risk baking inequality into the system all over again.

This means that our measures of quality cannot be based only on whether we’ve improved quality on average; we also have to measure the impact of quality improvement efforts on those with the greatest need. Payment models that seek to reward quality over quantity, like Medicare’s Merit-based Incentive Payment System (MIPS), often do not reward providers for reducing health disparities within their practice, Ojo and colleagues note. As a result, these payment models have had only a mixed effect on reducing disparities. In fact, providers that care for more low-income people of color are sometimes punished financially because it’s harder to meet the clinical targets.

Add equity metrics to value-based care

Ojo and colleagues recommend that pay-for-performance models include benchmarks for health equity, such as measures of what the hospital is doing to proactively reduce health disparities. These can take the form of disparities impact assessments and health equity reports within hospitals’ quality improvement assessments. And importantly, these metrics should have some weight– there should be financial consequences for hospitals not tracking their progress on equity.

The authors also point out that health outcomes are often compared across hospitals to measure performance, but rarely are disparities within hospitals being measured. This is why hospitals that care for patients with greater social risk are often penalized. While some policy experts have recommended adjusting quality measures for social risk, Ojo and colleagues point out that this method “pathologizes race and threatens to normalize lower quality of care for Black patients.” However, if we measured disparities in health outcomes within hospitals, all hospitals would be held accountable for how they serve the most vulnerable in their community.

Focus on upstream community benefits

Nonprofit hospitals are required to invest in charity care and other community benefits, activities that are supposed to promote community health and the social determinants of health. However, the vast majority of community benefit spending from nonprofit hospitals is on Medicaid shortfall, charity care, and health professions education– not on programs that prevent or improve chronic conditions before they require hospitalization.

“Given that health disparities are rooted in social inequities and nonprofits divert as much as $4 billion in tax dollars from local governments through property tax exemptions, health systems should prioritize community benefit spending on upstream social factors to maximize community impact,” the authors write.

One important investment hospitals can make is by employing more community health workers to improve access and outcomes. Community health workers (CHWs) are frontline public health workers who has a close understanding of the community they serve (often they are members of the community themselves). CHWs serve as an intermediary between health and social services and the community to increase access to serves, improve the quality and cultural competency of health care delivery, advocate for patients, and increase health knowledge in the community. CHW models have shown to improve primary care access, health care knowledge, chronic disease management, and reduce emergency department visits.

Since June, many hospitals and payers have put out statements promising to fight systemic racism in health care. Ojo and colleagues point out that “such gestures will remain nominal if they are not followed by major shifts in the way we care for Black patients.” Focusing on equity within value-based care models is an important way for hospitals to put their money where their mouth is.