Dear friends,

Value-based payment models have long been heralded as the next wave of health reform. However, research published last month in the New England Journal of Medicine showed that many of these programs have in fact been regressive, hampering the pursuit of health equity. The researchers’ found that “value-based payment initiatives have failed to advance health equity in large part because equity wasn’t prioritized during their design and implementation.”

 
That critical lesson applies generally–from value-based payment models to transforming Medicaid; if equity isn’t prioritized in the design and implementation of policies and practices, inequities will persist. That shouldn’t come as a shock to Upstreamists, who recognize that structural violence, societal practices, and social arrangements caused harms and inequities in the past, and continue to do so.

As we shared at last month’s Civitas conference, to combat the structures that cause harm, we need to build infrastructure for equity. This means embedding equity into policy design and implementation as well as into the critical community infrastructure that helps us translate those policies into action. And since structural racism and other forms of structural violence are “spatialized,” it also means that equity efforts–at all levels–need to be organized by place. That includes health equity efforts led by health systems and health plans, including Medicaid.

Here are three ways we need to work together to build equity infrastructure and drive equity-focused improvements, especially for Medicaid beneficiaries and our highest-need communities:

1) Organize data-sharing by place with a focus on equity.

Failing to collect data on critical aspects of people’s identities erases marginalized people from the data itself and hides inequities. Before the start of the COVID-19 pandemic, two-thirds of commercial health plans, half of Medicaid plans, and over one-quarter of Medicare plans reported missing race data for at least half of their membership. Capturing race, ethnicity, and language (REAL) data and looking for where disparities in outcomes exist can point to specific, underlying structural inequities and where additional services and social supports are needed. Health plans and systems need to:

• Improve their collection and sharing of REAL data. UC San Diego Health dramatically increased the collection and documentation of REAL data by taking three steps: interviewing everyone who interacted with patient demographic data to understand where problems with data collection occurred; adding new questions and response options to their electronic health record to better capture the nuance of patients’ identities; and improving training and methods of data collection. See more strategies for improving the collection and stratification of REAL data in HealthBegins’ “Toolkit to Advance Racial Equity in Primary Care.”

• Prioritize equitable data governance and community engagement. This means including individuals with lived expertise in data sharing, governance, and policy development. Health plans can use data governance frameworks to support the transition from communities’ dependence on ill-fitting data systems—those that can’t reach them, don’t apply to them, and don’t reflect their lived experience—to data sovereignty.

• Improve the collection and sharing of social needs data. Although more health systems and health plans are screening and referring patients for social needs, too few are using this information to gain more insights into patterns of health inequities in their patient population or community. Fewer still are sharing this information to inform broader public health and place-based efforts to optimize services and address the community-level social and structural drivers that generate these social needs in the first place. This is where next-generation Health Information Exchanges, including vanguard Social Health Information Exchanges, come in. They can be a critical component of infrastructure for equity.

• Improve racial equity in algorithms. Algorithms that do not account for the circumstances and concerns of economically and socially marginalized communities perpetuate and compound structural violence. Health plans need to create more opportunities for populations and communities with lived experiences to inform and access actionable, place-based health data and insights.

2) Organize equity-focused collaboration by place.

In support of whole person care, Medicaid programs across the country, like CalAIM are beginning to offer and invest in social and community supports, such as housing services and medically tailored meals. These are important developments in the pursuit of health equity. In order to ensure that care is provided in communities by local partners, it’s critical to build community-based organizations (CBOs) capacity to contribute to Medicaid, and in turn for Medicaid to support CBOs. Recently, HealthBegins launched an initiative to provide technical assistance to small CBOs throughout California to create the internal infrastructure needed to partner with Managed Care Plans.

At the same time, there are a wide-variety of place-based improvement efforts, but few have centered equity. That’s starting to change. One way Medicaid health plans and health systems can help align their internal health equity efforts with multi-sector, place-based work is through Health Equity Improvement Zones. This model, adapted by HealthBegins for health systems and payers, was directly inspired by a state-level public health strategy called Health Equity Zones, defined by vanguard states as a designated geographic area where a community identifies and eliminates specific health inequities, working with a coordinated set of institutional partners to effectively broaden and deepen their impact in a specific place.

The Rhode Island Department of Health (RIDOH), for example, currently supports 15 Health Equity Zone (HEZ) collaboratives with more than $30 million in public health funding. The issues that these collaboratives have tackled vary from addressing racism in local government and increasing civic engagement to reducing high rates of substance use and overdose and increasing access to affordable childcare. Health plans and health systems can similarly shift their own investments and realign their resources to support and participate in these community-driven models. Watch HealthBegins’ recent webinar on Health Equity Zones to learn more.

3) Strengthen community-driven governance and monitoring of equity efforts.

With notable exceptions including federally-qualified health centers, many health systems and health plans are still governed by boards whose members don’t typically belong to economically or socially marginalized communities and who don’t have lived experience dealing with structural inequities, including structural racism. This lack of diversity among health care boards and leadership reflects a philosophy of governance that has allowed structural harms and inequities to persist. In contrast, as organizational psychologist Judy Freiwirth writes, community-driven governance and monitoring is “based upon the philosophy that a constituent’s ‘lived experiences,’ knowledge, and right to self-determination are critical values for organizations to embrace.”

Embracing this approach means shifting both how boards work and the work boards do, and adapting new models–from community consultative boards and governance partnerships with communities to constituent-led boards–that cede more power to communities. It also means that health plans and systems should support and respond to community- and citizen-driven efforts to establish local collaborative governance for health, in which public, private, and nonprofit organizations (including CBOs) work together to review shared needs, make decisions, and monitor progress towards health equity. Supporting and joining in community-driven governance and monitoring systems also helps ensure the success of everything else a health system or health plan does to advance health equity.

The evidence is clear. When we don’t prioritize equity in the design and implementation of policies and practices, structural inequities will persist. These three steps can help courageous leaders in health systems and health plans counteract structural violence, prioritize equity, and achieve the Quintuple Aim, especially for Medicaid beneficiaries and our highest-need communities.

In solidarity,

Rishi Manchanda, MD, MPH.                                         Sadena Thevarajah, JD