Why It Matters
Accreditation.
Penalties.
Incentives.
Policies.
These have historically been common areas of focus for health care payers. Over the last few years, some payers have begun to use their considerable resources and influence to promote health equity. Now that some organizations have laid out their initial equity frameworks (including CVS and Blue Cross Blue Shield), what’s next? How can payers continue the ongoing journey of embedding health equity into their organizational practices? In the following interview, we connected with Institute for Healthcare Improvement (IHI) Director of Innovation Jeff Rakover and IHI Research Associate Alex Anderson (co-leads of a recent 90-day innovation team learning cycle) to find out more.
For the sake of clarity, what do you mean when you refer to health care payers?
Jeff Rakover: We mean mainly insurers or the folks who pay for health care. There are commercial payers, like Blue Cross Blue Shield, United Healthcare, or Aetna, for example. There are public payers, like Medicaid agencies. The Centers for Medicare and Medicaid Services (CMS) is a federal payer. They can be both public and private. Some patients do pay out of pocket, but for the most part, in the US at least, more and more folks are insured, and they have either a public or private payer who’s paying for their [health care] service.
Alex Anderson: For most people in the United States, their payer is a plan that is fully funded by their employer. Those big-name companies that we associate as insurers are actually administering the plan. They have different types of incentives, flexibility, and opportunities for implementing changes, so distinguishing the payers we're talking about is important. Different payers have different abilities not just to influence what happens for the lives that they cover directly, but what happens in the field at large.
What is an example of an organization doing effective equity work?
Jeff Rakover: The best work is hyper-local. It’s taking a few neighborhoods, using your data to identify the biggest gaps, and partnering with community-based organizations. This is something that Health Net in California is doing. They’re one of the Medicaid managed care plans. They also have commercial plans. They've worked on postpartum care, improving perinatal care, and improving birth outcomes. For example, they deployed doulas and partnered with community-based organizations to see what’s happening on the ground and what’s needed. Preliminary results from their data showed that C-section births were 50 percent lower in the group that had doulas in comparison with a similar group of women who did not. This collaborative model is something that is currently being analyzed and leveraged so that it can be spread across the state. Time and time again, you see that partnering with community-based organizations and really listening to the patients and communities is what works.
Also, using the data payers have is a huge asset to drive improvement and change. HealthPartners in Minnesota did similar work in a different clinical context. They have initiatives around mental health, vaccinations, breast cancer, and asthma. Recently, HealthPartners released a 10-year framework in partnership with the local community to address and reduce community asthma rates. The framework includes a plan for statewide partnerships, policy advocacy, and reducing environmental factors that trigger asthma episodes.
Alex Anderson: Also, Health Net’s entire leadership team is advancing and understanding what equity means for them as leaders in their organization. They use external coaches with expertise in equity work to lead structured time to think through what equity means from a leadership perspective. Saving dedicated space to improve their work as leaders — without the goal of doing a specific thing right now, but with the goal of developing the comfort and understanding of what it means to do anti-racism, equity-focused work in the day-to-day operations of a massive organization — is hard for a lot of organizations. It is not necessarily tangible in terms of deliverables or progress. But it seems to be a theme we see across lots of organizations trying to take equity on as a strategic priority. They set aside that type of space to explore and learn, develop understanding, create space for asking tough questions, or for rethinking or redesigning. That’s a good complement to the work of partnering in the community.
Where are some opportunities to make health equity more sustainable for payers?
Jeff Rakover: I see opportunities for making sure payers know how to use their data and how to collect data on race, ethnicity, sexual orientation, gender identity, and language in an effective way. Helping them build capability in the science of improvement is important, so they can support physician practices and others to make improvements and close equity gaps. Helping them understand the patient experience in a more complete way so that they are connecting to what's happening in patients’ lives is another opportunity. Penalties and incentives will always be part of the equation but focusing there can be limiting because providers already have so much on their plates. Empowering providers to work with patients in a different way is where the magic will happen.
Alex Anderson: I think the real move for sustainability is also about how we understand the history in terms of the ways that systems of oppression in the immediate community — like racism or sexism or classism — have affected access to treatment and outcomes with health and health care. It’s about pulling all those pieces together. We need that analysis piece, which requires the skill and capability development that Jeff mentioned, but with a lens of equity versus a lens of reporting or a lens of satisfying requirements for penalties and incentives. This shift in paradigm is something that is starting to happen with a handful of big payers around the country. It will likely be a pathway for payers for the next era of health care.
Editor’s note: This interview has been edited for length and clarity.
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