Over the past three years, advancing health equity has become a much higher priority for the LAN and CMS. And so LAN, about a year ago, created the HEAT, which is a diverse committee of equity experts from many of the different stakeholders. And the job of the HEAT is to help guide the LAN in its equity work. The guidance document you refer to, Advancing Health Equity through APMs, this provides an overall framework for thinking about equity in APMs as well as concrete, specific recommendations to help different stakeholders advance health equity through payment and care transformation.

Advanced health equity is a matter of will, that we actually know a lot about how to advance health equity. But to be frank, advancing health equity simply has not been a high enough priority for our nation as a whole or for those of us in healthcare. this is one of those special opportunities we have where that movement towards justice, that movement towards, of equity can be faster than in the normal era. So, your specific question about data. Data are critical because if we can stratify healthcare quality and outcomes data by social risk factors, such as race, ethnicity, insurance status, rural versus urban, gender, sexual gender minorities, a variety of different factors—
If we can then stratify those quality in outcomes data, we can identify disparities. And then, based upon where those disparities are, we can do what’s so-called root cause analysis to try to understand, in our particular setting, why do these differences by gender or by race, ethnicity exist? And then the solutions we have then to address those inequities need to be geared towards addressing those root causes in your particular setting, everything is sort of the context specific that what may be affecting things here in Chicago may be different than North Carolina or Washington. So that local root cause analysis has to be done looking at the data and then the interventions designed to address your local root causes.

The guidance document tries to both provide a big picture framework for everyone as well as starting to dive down into details of important areas. And so, on a big picture level, one might say that it’s not just payment reform for payment reform’s sake, that you don’t wanna be like a chicken with its head cutoff, just running around and trying things willy-nilly without thinking it through… it’s payment reform that needs to support and incentivize those care transformations that holistically address a patient’s medical and social needs to advance health equity. So, in some ways it’s just connecting the dot aspect. The document then concentrates upon two initial priority areas. What does care look like that would do that? So what is this good quality care? These would be things for example, that, do think about a patient holistically, do address the medical factors and the social factors that impede a patient’s best outcome. What can be done with payment to, again, incentivize advanced health equity?
One can, I think about value-based payment programs, pay-for-performance programs that, explicitly incentivized, for example, reducing a disparity and outcome between a [more] less advantaged group. A second area of payment I would think about is what I call infrastructure. One of, the wonderful things about APMs is that through different types of funding mechanisms, you do have the ability to have upfront money that can then be used to invest in what I call infrastructure, to address health equity. And these can be things like team-based care or community health workers, which typically aren’t reimbursed by many payment systems or beefing up the data systems to be able to, for example, screen for social determinants of health to be able to have the data systems that help link to appropriate partners in the community that can help with the social determinants feedback loops so that the healthcare system then knows what’s being done to address that patient’s social needs.
Those are three examples of some infrastructure. A third element of payment I would highlight is risk adjustment. This had been identified by HEAT as a key issue that wasn’t dealt with in detail in the current document, although it is the first priority topic for the HEAT’s ongoing work to start exploring risk adjustments. In fact Aparna, you’re one of the experts that the HEAT’s working with to help with this particular area. But the issue being that, on one hand, you don’t want to penalize those providers, those organizations that care for a lot of patients with high social risks. These are often patients that are, have more challenges, are harder to improve their quality of care and outcomes. So, you don’t want to penalize a provider for taking care of those patients. So, probably we need to do something like risk adjusting payment for both of a patient’s medical and social risk so that this ongoing work now. At the same time though, we don’t want to whitewash disparities. There are gonna be ways to think about payment care transformation, the flow of money, the incentives in the system, so that we can do both, of both not penalizing in fact, but rewarding people for taking care of patients that high social risk, at the same time that we don’t whitewash away inequities and that whatever we do works towards improving the equity, improving the outcomes of those at risk.

I’ll give you two or three examples. So, one is for another program I co-direct, this Merck Foundation program called bridging the gap program of working with eight different urban and rural communities to improve diabetes population outcomes. And one of our most successful teams is west, UPMC Western Maryland. This is a system, health system that’s located in the far western part of Maryland. This is the panhandle part of Maryland, which is rural part of Appalachia. And as many of the listeners know the state of Maryland has an all-payer system where the health organizations are incentivized based upon their total cost of care. So UPMC Western Maryland, they have systems very similar to APMs where you have these total cost incentives mixed within quality-of-care metrics, incentives.
What they have found is that because of the financial incentives and the way that there’s flexible payment, they’ve invested in creating a center for clinical resources where this is a team that anyone can refer their patient, this team, which will do a holistic addressing of medical and social needs. And so they will do, for example, detailed social needs screening, they will do the partnerships with the community organizations that can help with the social needs. And they have found, like in this particular example this center has been able to, for their diabetes patients improve their sugar control as measured by A1C, as well as decrease all cause hospitalizations in this patient population. That’s one example. Second example I’ll give is that oftentimes some of the most exciting work is done at the state level where there’s, in the states you have fifty different states for experiments in terms of the Medicaid program.
So, the states of Oregon and Minnesota are two of the states that are most advanced regarding the way they have structured APMs and their different models for advancing health equity. So, Oregon, they have something called CCOs, which are essentially ACOs, and they basically incentivize equity. They have a flexible payment mechanisms to be able to more flexibly use money to address the medical and social needs. Minnesota, they explicitly call out racism and their managed care contracts are looking at ways to reward those managed organizations that are doing serious efforts to address racism, address equity. Third example I give is, again, from our bridge in the gap program. This is a federally qualified health center in Washington, DC named La Clinica that works with mostly immigrants, El Salvador population that have a complicated set of medical and social needs.

I point out maybe four lessons we learned from the pandemic. So one is that, that we need to be intentional about designing our solutions to advance health equity. So, I think we found, for example, like the rollout of the COVID vaccine where equity, frankly, was not prioritized highly enough. We had the national guidelines that, that didn’t lead to adequate allocation of, of vaccines or systems or processes to get vaccines equitably in the community. So, the point being that we need to intentionally design APMs to advance health equity. It goes along line with the APMs vision regarding its role in population health, the ethics of, of serving the community and the social justice imperative we’ve seen with, with COVID. And in general, with healthcare, a second lesson from the pandemic is that we need to address social determinants of health.
Oftentimes the medical parts of the problem are the easier problems to face, as opposed to some of the social determinants of health we found, like for COVID and the need to think about patients holistically in terms of their medical issues through economic use the health beliefs, if we’re going to, in this case, for example, get communities vaccinated. A third is behavioral. And so that and any of the clinicians here know that behavioral issues are such a heavy component of many of the patients we see there’s this famous quote from Francis Collins, the most recent NIH director, which some people may not heard of yet, where he said that he was asked, “well, now that you’ve finished your term as NIH director, is there anything you wish you would’ve done differently?”
And one of the first things he said was that I really wish I had put more money into the behavioral science research, and I think it was coming from his perspective and having to deal with COVID and seeing all this vaccine, he’s seen it all. And again, like any clinician will say, well, yeah, coming to the club a little bit late, but great that he came to that recognition that again, what any clinician and a person sees right off the bat, behavioral issues, just such an important part of overall health. The last thing I’ll mention again is we learned from the pandemic that racism is a big issue. And so, we need to have an explicit anti-racism lens as we think about some of the equity Issues within APMs and nationally.

I’ll point out three different trends, which I think are already happening and I think will accelerate. One is this move from still a predominantly medically oriented healthcare system. The one that thinks about patients truly in a more holistic way as people that have medical and social issues and as individuals who also live within communities. So, APMs, I think be part of that, that trend also. Second general trend is a shift from a predominantly inpatient-based healthcare system to one that increasingly shifts care to the home in virtual settings. We saw with telehealth of the value that telehealth and we need to do more about shifting things out of the hospital. We can probably be more efficient in terms of the mix of what can be, needs to be done.
So, that’s an exciting shift. A third shift I would say is that we’re gonna see over time, just increasing amounts of real-time health data and social data available. And now, then, with advances in machine learning, artificial intelligence, we should have faster ways to process, analyze, and then respond to these real-time data with systems. We need to create, to be able to handle this data and then, to then respond in terms of how it interacts them with the patients. It’s all very, very exciting. The trends. I would say though, that all these have potential advanced health equity, health equity, if we address them appropriately, but all these three trends also could exacerbate inequities if we don’t basically be intentional about designing our systems to address equity issues.