'The bar is very low right now’ for addressing disparities

When Meagan Brown, a collaborative scientist at the Kaiser Permanente Washington Health Research Institute, surveyed the communities the health system serves, she and her team found massive disparities in social risk among Black, Hispanic and multiracial people. Income was the underlying driver of differences.

“This speaks to a generational and compounding impact of wealth over time that intersects with employment and healthcare,” Brown said during Modern Healthcare’s recent Social Determinants of Health Symposium.

Kaiser has partnered with social services organizations to combat some of the inequities. The collaborations will help save the healthcare conglomerate money in the long run, according to Dr. Anand Shah, the system’s vice president of social health.

Addressing issues that affect a person’s overall wellness could soon play an even greater role in healthcare organizations’ financial viability.

In an effort to promote more preventive health practices, the Center for Medicare and Medicaid Innovation is testing 28 models that would base provider payment for clinical services on quality and value. The number is expected to grow in the coming years, said CMMI Chief Medical Officer Dr. Dora Hughes.

The alternative payment models, meant to ease the industry away from the typical fee-for-service model, vary by targeted medical condition, practice location and type of services rendered. Perhaps the best-known is ACO REACH, or the Accountable Care Organization Realizing Equity, Access, and Community Health Model. The value-based framework, which replaced the Global and Professional Direct Contracting Model earlier this year, requires participants to identify and outline plans to mitigate disparities among Medicare beneficiaries.

In August, CMMI announced 110 ACOs had been provisionally accepted to participate in the model beginning Jan. 1, 2023.

Another model, as outlined at the symposium, addresses social issues alongside clinical care in six states for children on Medicaid or the Children’s Health Insurance Program. Its goals are to improve child health and reduce avoidable inpatient stays and out-of-home placements, such as foster care.

A third model aimed at maternal opioid misuse focuses on postpartum mothers on Medicaid. Eight organizations use enhanced care coordination and connection with social services to improve outcomes for mothers and their babies.

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CMMI is also paying attention to the number of beneficiaries from underserved communities participating in their models. For example, patients in the Primary Care First model offered in 26 regions are concentrated in more affluent neighborhoods, with very few opportunities in low-income areas.

“There’s a relative imbalance [in] where primary-care sites are providing care to where the most low-income and African-American residents reside,” Hughes said.

Shifting that paradigm has required analysis and reflection. CMMI uses available race, ethnicity and socioeconomic data to find holes in its models’ coverage. It then considers whether the model could disincentivize providers in the identified gaps to adopt it.

The innovation center found that its algorithms for eligibility screening may have contributed to an underrepresentation of low-income people of color.

“We intend to continue doing more work to identify implicit bias in our models,” Hughes said. “This is an important area of focus for all of us.”

Healthcare organizations looking to narrow disparities should start by listening to the needs of the communities they serve, said Dr. Ana Pujols McKee, executive vice president and chief medical officer of The Joint Commission, an accrediting body.

For example, providers could run a study to see whether patients who live in specific ZIP codes are more likely to miss appointments—which likely represents a transportation problem that needs to be solved.

“There’s a fundamental lack of understanding about where the impediments are, where the barriers are, in these communities,” McKee said. “Martians didn’t come down and create those impediments. Our society made those impediments. And we have to fix them.”

Accountability frameworks like those established by The Joint Commission and other accrediting bodies are meant to set organizations up for success, she said.

“This is an incremental approach to improving inequities,” McKee said. “Every three years the bar will be raised. The bar is very low right now.”

She pointed to the economic benefits of equalizing outcomes: “A mammogram costs a lot less than advanced cancer treatment to the breasts.”

Some health systems have begun treating disparities like any other adverse outcome and working with clinical teams to address them accordingly.

At Brigham and Women’s Hospital, the quality and safety team started integrating equity into performance assessments in 2019. The team added stratifications to its quality data for race, ethnicity, language, gender and age, among others.

Now, every quality assessment includes an equity-informed mindset, said Karen Fiumara, vice president of patient safety at Brigham and Women’s Hospital. “We know that you cannot have high-quality and safe care if that care is not equitable,” Fiumara said. “We need to bake this into our DNA on how we do this work moving forward.”