Theory of Change

This Theory of Change visually illustrates how alternative payment models (APMs) can be structured to advance health equity. To provide stakeholders with a starting point for action, Advancing Health Equity through APMs offers guidance on how to operationalize two design elements (bolded below). The HCPLAN’s Health Equity Advisory Team (HEAT) selected these two elements based on their potential for impact, necessity, and feasibility.

Click on the visual below to learn more about each piece of this Theory of Change.

Driver Diagram


More Equitable Health Outcomes

By incentivizing and supporting care delivery changes that make care more equitable, intentionally designed APMs can help mitigate the negative impact that explicit and implicit biases and structural racism have on historically marginalized communities and the providers that serve them, driving better patient outcomes, reducing disparities, and advancing health equity.


Change starts by incorporating APM design elements that incentivize and support equitable care delivery and outcomes.

Payers and purchasers can adopt promising design elements into APMs in an aligned manner to maximize provider uptake and the positive impact of APMs on health equity.
Providers participating in these APMs can make changes in care delivery that will enable them to advance health equity in a way that is flexible and aligned with fulfilling their mission.
Individuals, families, their communities, and other relevant stakeholders can work with payers, purchasers, and providers to ensure changes in health care delivery and payment through APMs reflect their needs and preferences for change.


APMs leverage three inter-related features that are especially important for advancing health equity:

These features:

  • Hold provider organizations accountable for delivering better care and achieving better health outcomes for all people;
  • Give providers greater flexibility to deliver whole-person care, consistent with each individual’s community, culture, and identity; and
  • Increase accessibility and use of effective, appropriate, and affordable care and services.


Multi-payer alignment plays an important role in creating the business case for providers to adopt APMs and change how care is delivered. Advancing Health Equity through APMs points to the following areas where alignment within the design elements is key to reducing unnecessary administrative burdens:

  • Developing a mutual understanding of the services and staffing approaches that promote culturally and linguistically appropriate person-centered care.
  • Developing an aligned set of monitoring measures to reflect culturally and linguistically appropriate person-centered care and meaningful care delivery redesign.
  • Adopting one aligned health equity performance measure set, stratified by race, ethnicity, language, and other characteristics (e.g., the health equity performance measure set), which reflects the most substantial health disparities in the relevant state or region.
  • Adopting a common methodology to measure the size of health disparities and year-over-year changes. This methodology must measure disparities by self-reported race, ethnicity, and language, and preferably disparities by disability status, sexual orientation, gender identity, and geography.