Value-based care launched more than two decades ago in a push to improve quality while curbing costs. Now policymakers want to make bridging healthcare disparities an additional goal of the payment models.
A year after the 10-year anniversary of the Center for Medicare and Medicaid Innovation, regulators are evaluating the efficacy of existing payment models and the impact they have had on bridging—and dividing—outcomes and costs across patient groups.
At the start of the year, the Centers for Medicare and Medicaid Services issued a request for information on metrics that could be used to assess equity achievement among providers. Federal regulators also recently unveiled their strategic plan, in which providing equitable care is a central feature. CMS Administrator Chiquita Brooks-LaSure, who is the first Black woman to lead the agency, has also made it clear that bridging disparities holds a strong personal significance to her.
“For every decision being made, we’re asking ourselves, ‘How is this action advancing health equity?’ ” Brooks-LaSure wrote in a September blog post.
Along with the federal government, providers are also increasingly viewing healthcare equity as taking precedence, with 58% of health systems identifying equity as a top priority in 2021, more than double the 25% from two years ago, according to a survey from the Institute for Healthcare Improvement. Insurers will be a critical part of further incentivizing health equity among providers. And once CMS approves new or updated models, most private payers are likely to follow.
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But incorporating health equity into physician payment isn’t as simple as layering equity onto existing models.
Previous value-based care payment programs have actually dinged hospitals that serve underserved communities. Hospitals that cared for a high proportion of Black adults were penalized more frequently by CMS value-based programs than other hospitals in 2019, even after accounting for safety-net status, according to a March study published in the Journal of the American Medical Association.
Other programs, like the Medicare Advantage star ratings, incentivized organizations to withhold best-practice information from one another and led some risk-based entities to cherry-pick patients.
For value-based care to truly reflect all patients, payers and providers must build a stronger data infrastructure and collection system, invest in social determinants of health resources and listen to the communities they serve to focus on their individual needs, observers say. Most importantly, the commitment to equity must be embedded in every function across the organization—and payers and providers should begin strategizing now, said Dr. Mai Pham, former head of CMMI.
“It’s always better when you have a clear theory of action, and you have an overall strategy,” Pham said. “Not, you know, one corner of the company thinking about value-based payment over there, and a separate corner of the company thinking about social drivers over here.”
CMS’ largest hospital-based value-based care programs would be a natural starting point for federal regulators to evaluate and update to measure equity, given their size offers them the largest impact, said Dr. Rishi Wadhera, head of health policy and equity at the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center. These programs include the Hospital Readmissions Reduction Program, which incentivizes hospitals to reduce avoidable readmissions through improved communication and care coordination; the Hospital Value-Based Purchasing Program, which rewards acute-care hospitals for improving the inpatient hospital experience; and the Hospital-Acquired Condition Reduction Program, which reduces Medicare payments for hospitals that rank in the lowest quartile for patients acquiring new conditions in the hospital.