A Call to Advance Equity in Health Care Payment

Changes in health care payment have done little to address health care disparities – one of the most critical problems in the US healthcare system. The US cannot make meaningful progress without realigning payment around equity. We call on the health care community to undertake this work without delay.

 

Payment is a powerful motivator. In the US, clinicians are paid more for providing more services, regardless of how they affect patients’ health. This dynamic has fueled an inefficient system in which care is often unaffordable and produces disappointing outcomes for many Americans.

 

Recognizing the misalignment between the payment and health, policymakers have spent a decade shifting financial incentives toward “value-based payment” that emphasizes better health outcomes and cost-conscious care. This approach has created a major cultural shift and prompted work across the healthcare industry to reduce waste and improve care.

 

But these changes have done little to address health care disparities – one of the most critical problems in the US healthcare system.

 

In a recent article published in the Journal of the American Medical Association, several of us highlighted why value-based payment has not led to more equitable care. Disparities have been widely viewed as “unintended consequences” – issues to monitor after making payment changes rather than address beforehand. While it tries to reward good health outcomes, value-based payment also does not account for other factors, such as social drivers of health, that impede better outcomes for historically marginalized groups like racial and ethnic minorities and individuals with low income.

 

The US cannot make meaningful progress without tackling these issues and realigning payment around equity. To that end, we call on the health care community to support and commit to advancing health equity in payment – a set of principles, policies, and methods for using health care payment to achieve greater equity.

 

This call is grounded in several beliefs. First, because intention precedes implementation, we cannot meaningfully address disparities so long as they are tacitly accepted as unintended consequences of how we pay for care. We acknowledge the need to set a new, explicit intention to pay for health care in ways that help eradicate inequity. This intention includes both removing existing payment incentives that unintentionally undercut equity as well as creating new incentives that promote it.

 

Second, payment changes should address differences in how a clinician or organization treats different types of patients as well as differences between clinicians or organizations, which may be influenced by broader social and structural factors. Third, no payment system changes occur in a vacuum, and efforts to advance health equity in payment should utilize beneficial parts of existing data, technology, infrastructure whenever possible.

 

In that context, key work areas involve (a) adapting or pivoting from existing performance measures to develop ways to measure disparities within payment arrangements; (b) aligning payment incentives to directly support the goal of eliminating disparities; and (c) implementing changes into practice by harmonizing existing and new equity-focused incentives. Achieving these goals will require several steps in the coming years:

 

Convene a multi-stakeholder coalition. The work to advance equity through payment requires the voices of patients, communities, clinicians, health care organizations, insurers, employers, and other purchasers. We need diverse perspectives to guide the substantive changes needed in payment policies, programs, and methods.

 

Formally incorporate equity into the concept of value-based payment. In health care, value has been widely understood as quality relative to cost. In turn, value-based payment thus far has hinged on whether reforms improve quality and/or reduce costs overall – how large the benefits are across all patients. But nowhere in the value equation is the concept of equity – how even the benefits are between different groups of patients. This is a glaring omission that future work should address. We cannot be comfortable accepting concepts of value that do not consider equity, or improvements in value that come at the expense of the disadvantaged.

 

Create an implementation roadmap. Centering payment on equity-based goals is not a simple “flip of the switch” effort. We must articulate a roadmap for implementing real-world payment programs and methods that will make progress toward greater health equity. This roadmap should provide guidance on when and how to overcome barriers; harness aspects of existing payment system; make the necessary advances in data collection, performance measurement, and incentive design; and evaluate the impact of enacted changes.

 

Set bold, longitudinal goals. One way to demonstrate an intention to align payment with equity is by setting bold goals for changes in payment. For instance, health care leaders could set goals over time to incorporate equity measures into all payment models or tie a proportion of all reimbursement to equity measure performance. Decision-makers could also set goals for incorporating equity-focused payment changes into practice.

 

Conduct evaluations. Several decades of experience have made it undeniably clear: historically marginalized groups like racial and ethnic minorities and individuals with low income face widespread health care disparities. Yet remarkably little work has evaluated whether and how new payment methods affect disparities for these populations. Efforts to advance health equity in payment should be coupled with evaluation, the findings of which can then guide work evolution and refinement. Ultimately, we can only change and improve on what we measure and motivate.

 

Of course, this work will require great effort, and no payment approach is immune to unintended consequences. Reimbursement is also just one among many areas where changes are needed to address inequity. But payment is a powerful motivator, and intentional changes can harness it into a powerful solution to inequity. The health care community should undertake this work without delay.  

Amol S. Navathe, MD, PhD

University of Pennsylvania

Risa J. Lavizzo-Mourey, MD, MBA

University of Pennsylvania

Joshua M. Liao, MD, MSc

University of Washington

 

Total Signatures

77

Signatories

(listed alphabetically)

George M. Abraham, MD, MPH

President

American College of Physicians

 

Toyin Ajayi, MD

Co-Founder and President

Cityblock

 

Katrina A. Armstrong, MD

Physician in Chief, Massachusetts General Hospital

Jackson Professor of Medicine, Harvard Medical School

 

Vineet Arora, MD, MAPP

Herbert T. Abelson Professor of Medicine

Dean for Medical Education, Pritzker School of Medicine

The University of Chicago

 

David A. Asch, MD, MBA
John Morgan Professor

University of Pennsylvania

 

Chethan Bachireddy, MD, MSc

Chief Medical Officer

Virginia Department of Medical Assistance Services


Michael Barnett, MD, MS

Assistant Professor

Harvard T.H. Chan School of Public Health

 

Richard J. Baron, MD

President and Chief Executive Officer

American Board of Internal Medicine

 

Andrew Bazemore, MD, MPH

Senior Vice President of Research and Policy

American Board of Family Medicine

 

Jay Bhatt, DO, MPH, MPA

Instructor

University of Illinois Chicago School of Public Health

 

David Blumenthal, MD, MPP

President

The Commonwealth Fund

 

Kevin Bozic, MD, MBA

Chair, Department of Surgery and Perioperative Care

Dell Medical School, The University of Texas at Austin

 

John Brumsted, MD

President and Chief Executive Officer

University of Vermont Health Network

 

Sean Cavanaugh, MPH

Chief Policy Officer and Chief Commercial Officer

Aledade

 

Christopher Chen, MD, MBA

Medical Director, Medicaid

Washington Health Care Authority

 

Aneesh Chopra, MPP

President, CareJourney

Former Chief Technology Officer of the US (2009-2012)

 

Mandy K. Cohen, MD, MPH

Secretary

NC Department of Health and Human Services

 

Patrick Conway, MD, MSc

Chief Executive Officer of Care Solutions, Optum

Former Director, CMMI

 

David Cutler, PhD

Professor, Department of Economics

Harvard University

 

Mohammad Dar, MD

Senior Medical Director

Massachusetts Medicaid (MassHealth)

 

Scott W. Delaney, ScD, JD, MPH

Department of Social and Behavioral Sciences

Harvard T.H. Chan School of Public Health

 

Allan Detsky, MD, PhD

Professor of Medicine and Health Policy, Management and Evaluation

University of Toronto

 

Shannon Dowler, MD

Chief Medical Officer

North Carolina Medicaid

 

Andrew Dreyfus, BA

President and Chief Executive Officer

Blue Cross Blue Shield of Massachusetts

 

Ezekiel J. Emanuel, MD, PhD

Vice Provost for Global Initiatives

Levy University Professor

University of Pennsylvania

 

Utibe R. Essien, MD, MPH

Assistant Professor of Medicine

University of Pittsburgh School of Medicine

 

A. Mark Fendrick, MD

Professor of Internal Medicine and Health Management & Policy

University of Michigan

 

Jose F. Figueroa, MD, MPH

Assistant Professor

Harvard T.H. Chan School of Public Health

 

Mark Friedberg, MD, MPP

Senior Vice President, Performance Measurement & Improvement

Blue Cross Blue Shield of Massachusetts

 

Vivek Garipalli, BBA

Chief Executive Officer

Clover Health

 

Paul Ginsburg, PhD

Professor of Health Policy, Price School of Public Policy

University of Southern California

 

Kate Goodrich, MD, MHS

Senior Vice President, Enterprise Clinical Management

Humana

 

David C. Grabowski, PhD

Professor of Health Care Policy

Harvard Medical School

 

Julian Harris, MD, MBA

Chairman and Chief Executive Officer

ConcertoCare

 

Jonathan Jaffery, MD, MS, MMM

Professor of Medicine, University of Wisconsin

Chief Population Health Officer, UW Health

President and Chief Executive Officer, UW Health ACO

 

Sachin H. Jain, MD, MBA

President and Chief Executive Officer

SCAN Group and SCAN Health Plan

 

J. Larry Jameson, MD, PhD

Executive Vice President, University of Pennsylvania Health System

Dean, Raymond and Ruth Perelman School of Medicine

University of Pennsylvania

 

Karen E. Joynt Maddox, MD, MPH

Associate Professor

Washington University School of Medicine

Barbara Jung, MD

Professor and Robert G. Petersdorf Endowed Chair in Medicine

University of Washington

 

Allen Kachalia, MD, JD

Senior Vice President, Patient Safety and Quality

Johns Hopkins Medicine

 

Ali Khan, MD, MPP

Executive Medical Director

Oak Street Health

 

Joe Kimura, MD, MPH

Chief Medical Officer

Atrius Health

 

Bob Kocher, MD

Adjunct Professor, Stanford University School of Medicine

Partner, Venrock

 

Harlan Krumholz, MD, SM

Harold H. Hines, Jr. Professor of Medicine

Yale School of Medicine

 

Winston Liaw, MD, MPH

Chair, Department of Health Systems and Population Health Sciences

University of Houston College of Medicine

 

Monica L. Lypson, MD, MHPE

President

Society of General Internal Medicine

 

Emily Maxson, MD

Chief Medical Officer

Aledade

 

J. Michael McWilliams MD, PhD

Warren Alpert Foundation Professor of Health Care Policy

Professor of Medicine

Harvard Medical School

 

Craig Monsen, MD

Chief Medical Information Officer

Atrius Health

 

John Morgan, MD

Chief Clinical Innovation Officer

Virginia Department of Medical Assistance Services

 

Christopher Moriates, MD

Assistant Dean for Health Care Value

Dell Medical School, The University of Texas at Austin

 

Mark Mugiishi, MD

President and Chief Executive Officer

Hawaii Medical Service Association

Blue Cross Blue Shield of Hawai’i

 

Karen Murphy, PhD, RN

Executive Vice President and Chief Innovation Officer

Geisinger

 

David Nash, MD, MBA 

Founding Dean Emeritus

Dr Raymond C and Doris N Grandon Professor 

Jefferson College Population Health

 

J. Nwando Olyaiwola, MD, MPH

Chief Health Equity Officer

Humana

 

Kavita Patel, MD, MS

Primary Care Physician, Mary’s Center

Non-Resident Fellow, Brookings Institution

 

Hoangmai H. Pham, MD, MPH

President

Institute for Exceptional Care

 

Michael Pignone, MD, MPH

Professor and Inaugural Chair, Department of Internal Medicine

Dell Medical School, The University of Texas at Austin

 

Peter Pronovost, MD, PhD

Chief Quality and Clinical Transformation Officer

University Hospitals

 

Rahul Rajkumar, MD, JD

Chief Operating Officer of Care Solutions, Optum

Former Deputy Director, CMMI

 

Paul G. Ramsey, MD

Chief Executive Officer, UW Medicine

Executive Vice President for Medical Affairs

Dean of the School of Medicine

University of Washington

 

Rahul Rekhi, MS

Director, Lazard

Former Staff Economist, White House Council of Economic Advisors

 

Wayne Riley, MD, MPH, MBA

President

SUNY Downstate Health Sciences University

 

Lisa Rotenstein, MD, MBA
Assistant Medical Director for Population Health & Faculty Wellbeing

Brigham and Women’s Hospital

 

Valinda Rutledge, MBA

Executive Vice President of Federal Affairs

America’s Physician Groups

 

Jaewon Ryu, MD, JD

President and Chief Executive Officer

Geisinger

 

Dana Gelb Safran, ScD

President and Chief Executive Officer
National Quality Forum (Incoming, August 2021)

 

Eric C. Schneider, MD, MPH

Senior Vice President for Policy and Research

The Commonwealth Fund

 

Allyson Schwartz, MSS

Member of Congress, 2005-2015

 

Thomas Sequist, MD, MPH

Chief Patient Experience and Equity Officer, Mass General Brigham

Professor of Medicine and Health Care Policy, Harvard Medical School

 

Lisa Simpson MB, BCh, MPH

President and Chief Executive Officer

AcademyHealth

 

Mark D. Smith, MD, MBA

Professor of Clinical Medicine, University of California, San Francisco

Former President and Chief Executive Officer, California Health Care Foundation

 

Robert M. Wachter, MD

Professor and Chair, Department of Medicine

University of California, San Francisco

 

Rachel M. Werner, MD, PhD

Professor, Perelman School of Medicine

University of Pennsylvania

 

Jennifer Wiler, MD, MBA

Professor and Chief Quality Officer

UCHealth Denver Metro

 

David R. Williams, PhD, MPH

Florence & Laura Norman Professor of Public Health

Professor of African and African American Studies and of Sociology

Harvard University

 

Judy Zerzan-Thul, MD, MPH

Chief Medical Officer

Washington Health Care Authority