August 29, 2018

Healthcare has experienced a meteoric rise in the use of quality measures to determine payment through the Hospital Value-Based Purchasing Program (HVBP), the Merit-Based Incentive Payment System (MIPS) and other programs.  An article in Health Affairs argues that what are missing from these programs are measures and payment incentives tied to one of healthcare quality’s most fundamental drivers—the promotion of health equity and the reduction of healthcare disparities across vulnerable and underserved demographic and socioeconomic groups.

Few value-based programs directly target health equity, and that key missing element hinders efforts to improve the quality of care, according to researchers from the Robert Wood Johnson Foundation and the National Quality Forum (NQF).  “Quality improvement initiatives without a focus on disparity reduction have had mixed results in influencing disparities and, in some instances, have the potential to widen disparities,” they state.

The authors share a four-step road map for healthcare providers, developed by the NQF, to promote health equity and reduce disparities, using disparities in hypertension among African-Americans as an example to illustrate how the road map can be used.  According to the road map, providers should:

• Identify disparities and sort them by priority.  Prioritize interventions that can move the needle relatively quickly. Target large disparities and relatively simple implementations first.

  All quality measures can be viewed through a disparities lens, according to the authors, but providers can use four criteria to identify the best measures for a disparities focus:  1) prevalence of the target condition, 2) size of the disparity, 3) strength of available evidence for strategies to reduce the disparity, and 4) ease and feasibility of the improvement.

  Not all of these criteria necessarily have to be met in order for a measure to become a priority, they note.

• Rely on evidence-based interventions. Look across all levels of the healthcare system to identify interventions that have been shown to improve outcomes, and start with those.  For example, healthcare organizations have developed dozens of effective interventions to address disparities in hypertension among African-Americans. Evidence-based interventions can be deployed at the patient-family, provider, organization, community and policy development levels, or some combination of these.

  The authors argue that, at the federal level, “MIPS could provide rewards for implementing many of these community and quality improvement activities, and more healthcare organizations would be likely to address fundamental determinants of health if the determinants were measured and rewarded in value-based purchasing programs.”

  In addition, outcomes of health equity initiatives should be monitored to detect relative and absolute improvement among targeted groups and to add to the knowledge base for use by other healthcare providers.

• Develop better performance measures for healthcare equity. Invest in partnerships and collaborations both inside and outside the organization to identify the causes of disparities and develop best practices.

  Advancing equity means improving both access to and quality of care, and no single intervention will eliminate disparities, according to the authors.  Providers should incorporate the following five elements into their efforts: 1) build collaborations and partnerships to address factors outside the organization’s or system’s direct control that contribute to disparities; 2) create a culture of equity that makes reducing disparities a priority; 3) create structures that promote equity, such as team-based care and disease management programs; 4) promote equity by measuring medication affordability and the ability to pay for treatment, which affect adherence to care plans; and 5) ensure that care is high quality by using evidence-based interventions and assessing whether those interventions actually reduce disparities.

• Provide incentives to reduce disparities.  Use equity as a quality endpoint. Incentivizing healthcare providers to work on equity could also lead to the discovery and development of new interventions.

  “The shift to global payment, capitated payment and bundled payment—part of the movement toward value-based payment—could support the infrastructure for interventions that reduce disparities. However, these payment approaches must be coupled with explicit incentives to address social determinants of health and reduce disparities,” the authors conclude.

The complete Health Affairs article is available here.