Community engagement, investment, and quality metrics were spotlighted as potential solutions to address health inequities affecting marginalized communities nationwide.
Systemic health and social factors have a significant impact on health care quality and access in the United States, and race, zip code, and data are a few of the several variables contributing to equity concerns for underserved communities nationwide, according to panelists of a Wednesday panel discussion at AHIP 2022.
Opening the session, “Taking Action on Health Equity,” Dora Hughes, chief medical officer of CMS’ Center for Medicare and Medicaid Innovation (CMMI), noted that 2 key issues remain at the forefront regarding health inequity: the structural factors impeding health care access (eg, lack of providers and insurance) and the disparities in quality of care that have historically affected minority populations.
Racial and residential segregation in the United States has led to factors such as education level, income, and zip code having disproportionate impacts on health outcomes, including for maternal morbidity and cancer.
“Even for those that aren’t facing access barriers, there’s still quality of care disparities. We continue to have Blacks, Latinos, other people of color who are not receiving recommended care,” said Hughes.
The lack of data for underserved communities was mentioned as a major factor limiting actionable discussions with payers, providers, and health plans. In taking an intentional approach toward care gaps, Joneigh S. Khaldun, MD, MPH, FACEP, vice president and chief health equity officer, CVS Health, said it begins at the top with policies, programs, and processes.
“Any quality metric, you should be looking at it by race, ethnicity, disability status, sexual orientation, gender identity…As a payer, looking at prior authorizations, utilization management, and appeals processes, you need to be looking at that from an equity lens,” added Khaldun.
These gaps in data collection have become a hotbed issue for CMMI. Hughes acknowledged that when looking back at the first 10 years of their respective models, demographics of the beneficiaries being served were unknown and the majority of these patients were White and of higher income. Efforts made in recent years have shifted priorities to account for the full diversity of Medicare and Medicaid populations.
“Key to that is bringing in safety net providers, federally qualified health centers, rural health clinics, Medicaid providers, who can really improve research and bring along their populations so that they too are benefitted by the work that we’re trying to do…when the model ends and has been evaluated, how are we focusing on sustainability?,” Hughes asked. “We have learned a lot through our alternative payment models, and in many cases, the lessons that we have learned have not been more broadly adopted by the value-based community.”
Gaining widespread adoption of value-based care frameworks remains dependent on cost and investment, particularly for new entrants who do not have the capacity to take on risk. In forming policies and infrastructure that would be helpful to achieve health equity, Marshall H. Chin, MD, MPH, Richard Parrillo Family professor of Health Care Ethics in the Department of Medicine at the University of Chicago, and cochair of the CMS Health Care Payment Learning and Action Network Health Equity Advisory Team, highlighted 3 priorities, spearheaded by payment reform, that can support and incentivize care transformation.
“Money is a powerful driver of what we do in health care. So again, modules of payment reform supports and incentivizes those care transformations of health equity. The second is addressing the social drivers of health at the individual level in different patients, and then thinking creatively about partnerships with a variety of local community-based organizations which recognize social drivers,” said Chin.
“Unless you address the cultural equity part, you've reached a standstill, because you need to have a buyer, a solution on the frontline.”
Khaldun’s advice on health equity infrastructure improvements took on a more introspective focus by imploring organizations to ask questions that challenge their impact.
“How is this policy, program, process impacting historically marginalized communities? If you ask that question, quite frankly, you will see places where you can probably improve,” she said. “And then the second question is, have I included and engaged those historically marginalized communities in how I'm addressing my policy?"
During her time as the director and health officer for the Detroit Health Department, which has the highest infant mortality rate nationwide, community engagement efforts helped her recognize the lack of public transportation that was impacting residents’ access to medical care. Following a partnership with Lyft, Detroit experienced its lowest infant mortality rate in over 100 years in 2019.
“Metrics, data, engaging the community—you can actually see those disparities close....Equity is not just a program, it's embedded in what you do,” she concluded.