Disparity-Busting Payment Reform, Validated

Population health programs and other changes may offer solutions to long-standing healthcare disparities, research suggests.

Bundled payments, the push for population health, and other ongoing reforms offer tools for hospitals to address persistent health care disparities, according to researchers.

A report from the Institute for Healthcare Improvement (IHI) notes that health systems will need to address disparities in outcomes as they manage "population-level financial risk."

"Making health equity a strategic priority is greatly facilitated by sustainable funding through new payment systems at both the federal and state levels," the report notes.

The IHI report represents a growing awareness of the obstacles that limit health systems' ability to address long-standing disparities in care around "race, gender, age, sexual orientation, gender identity, disability status, and physical appearance such as height or weight."

But it offers more than a moral argument; it also makes a business case.

The committee that produced the report was chaired by Ronald Wyatt, MD, the medical director of The Joint Commission's Office of Quality and Patient Safety.

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The report notes "racial/ethnic minorities and individuals with limited English proficiency in the US are more likely to suffer an adverse event, have inappropriate and often costly tests ordered, have a longer length of stay in the hospital, be readmitted to the hospital, and have ambulatory-sensitive hospitalizations (i.e., admissions due to illnesses that can often be managed effectively.)"

So, Wyatt said, hospitals need to be aware of the need for interpretive services.

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"If you don't have interpretive services in your emergency department (ED), and you are relying on taxi drivers and family members and children of patients or other employees, I may get a bevy of tests, which becomes a quality issue on the overuse side or on the under-use side."

That can lead to recurring visits to the ED or readmissions, he says. Health systems need to be aware of the financial risk associated with disparities in health outcomes, because according to the report: "Meeting pay-for-performance targets for common chronic conditions such as diabetes will not be achievable without reducing disparities."

Making the business case for health equity can be "challenging," they note, but the report offers advice on how hospitals can address financial concerns. The document also advises hospitals to make equity a priority, address institutional racism, and make connections in the community.

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Data analysis is key to this effort, Wyatt says. Lisa A. Cooper, MD, agrees. She is the vice president for health care equity for John Hopkins Medicine and the lead author of a study in the current issue of Health Affairs.

"If there is a certain subset of your population that you are responsible for that isn't doing well, it is important for you to find out who those people are what the problem is so you can really target your programs appropriately," she said.

"Otherwise you are going to get penalized for your overall population metric not meeting goals based on these disparities."

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Her group's paper notes that some healthcare interventions designed to address disparities "fall short because of gaps in knowledge and translation." The gaps they identify—such as links to community services—mirror many of the recommendations in the IHI reports.

Under, fee-for-service, some hospitals struggling for a financially comfortable mix of patients may have failed to address the needs of underserved patients, many of whom are covered by Medicaid, the federal health plan for low-income and disabled patients.

'Last-Decade Thinking'

That will no longer be an option, Wyatt says. "The shift has gone to value and outcomes, so that whole idea about limiting your Medicare or Medicaid or uninsured patients really is last-decade thinking."

The IHI report suggests that the effort needs to go beyond patients. Hospitals need to look at how they treat their own staff. And, the push has to come from the top.

According to the report: "Health care leaders must be explicit that improving health equity is an organizational priority, both to support resource allocation for this work and to demonstrate that the organization is serious about reducing health disparities."