Health Affairs Essay: Use Value-Based Payment to Spread the Word


The authors make a case that using messengers to reach vulnerable populations isn't just a good idea. In the age of value-based reimbursement, it's becoming a necessity.

The best way to reduce healthcare costs is to prevent disease and complications, but bringing that message to vulnerable populations is not easy. A new essay in Health Affairs highlights how a simple idea—training barbers to carry health messages to formerly incarcerated men—could be a model for health systems.

The pioneering work of the Camden Coalition of Healthcare Providers long ago showed how a tiny percentage of patients can account for an oversize share of emergency department visits or Medicaid costs. Thus, identifying at-risk groups and targeting them for interventions is the key to improving health while cutting costs. One stumbling block has been the messenger—who are the community members who have the ear of the at-risk person, and how can the health system engage these messengers in the cause?

In Health Affairs, writers Ruth C. Browne, Marilyn Fraser, Judith Killen, and Laura Tollen write how ACCESS, a Brooklyn-based project of the Arthur Ashe Institute for Urban Health, knew just where to turn to engage men leaving prison or jail for health interventions. Up to a third of men leaving incarceration are eligible for Medicaid, so encouraging them to watch their blood pressure or cholesterol, or take advantage of health screenings, could bring significant savings.

Earlier health outreach efforts had revealed that 80% of barbers working on ACCESS projects had spent at least 1 night in jail. “This made them particularly credible messengers for our priority population of formerly incarcerated men and supportive women in their lives,” the writers note.

ACCESS trained barbers and stylists at 6 sites in Brooklyn with high rates of incarceration, and emphasized that the health messages “must be delivered in a way that could be useful to any member of the community who might know someone who had been incarcerated, instead of focusing solely on the formerly incarcerated themselves.” ACCESS surveyed patrons at the salons and barbershops before and after the intervention on questions like, “What are some signs of a heart attack? What is a normal blood pressure reading?” Videos on HIV health education played inside the shops.

The patrons’ ability to assess cardiovascular disease risk rose from 44% to 62%, and their understanding that condom use could reduce the spread of HIV increased from 77% to 88%.

What’s more, the writers say, the project shows the potential for health systems to use messengers in a similar way—and to pay for them. Until now, fee-for-service made no allowance for a program like training the barbers, but as Medicare moves to a value-based payment structure, it’s the results that will matter. Medicare has previously set a goal of 50% of fee-for-service payments being made through value-based models by 2018, and 90% of traditional payments must be tied to quality or value.

“We believe that achievement of such ambitious goals is heavily reliant on delivery systems’ ability to engage with a strong community-based infrastructure of credible health messengers,” the authors concluded. Not only is funding messengers a good idea, they argue, but the financial success of health systems “may depend upon doing so.”


Browne RC, Fraser M, Killen J, Tollen L. The messenger also matters: value-based payment can support outreach to vulnerable populations. Health Affairs Blog. Published July 10, 2017. Accessed July 11, 2017.

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