Achieving health equity is essential to achieving the triple aim. VBP models offer the opportunity to focus resources on people that historically and currently have experienced the most inequities because of inconsistent access to health care, limited or no availability of culturally and linguistically appropriate models of health care, and the masking of disparities caused by a lack of comprehensive and complete demographic data about patients.
To improve equity, you first need to understand your patient population by collecting race, ethnicity, language and disability (REALD) data.
- Review REALD guidance and resources developed by OHA.
- Assess, and if necessary, improve your capability to collect comprehensive and complete self-reported REALD data from all your patients.
- Stratify quality and access data to identify disparities, and what additional resources or clinical transformation might be needed to close those gaps.
- A provider may want to negotiate for upfront, capacity-building payments to support this data collection and stratification.
Payers can help providers identify patients who may be experiencing health disparities by sharing information they have about their members such as those who do not have a regular source of primary care and members at high risk.
CareOregon is engaged with the Alliance of Culturally Specific Behavioral Health Providers (“the Alliance”), a group of seven programs at five organizations, to codesign a new value-based payment model grounded in addressing health inequities and health disparities. The model, likely a 2C (pay-for-performance), will also have applicability to culturally specific providers outside of the Alliance.
The new model is expected to be fully implemented in January 2025 and has been intentionally developed in phases. Joint decisions on areas of focus by year have been:
- 2020 and 2021 implementation: Support provider stability and quick repositioning of services during the pandemic and grant to Alliance for time and capacity to be co-facilitators
- 2022 implementation: Enhanced payment differential of 10% for culturally specific treatment services related to workforce and staffing; Health Related Services used as a financing mechanism to fund outreach and engagement which many agencies used to support Traditional Health Worker services.
- 2023 and 2024 planning: Alliance and CareOregon developing a culturally specific care model, quality measures and ongoing payment structure(s) for January 2025 implementation.
VBP Toolkit Menu
- Understand VBP models
- Educate your team on VBP terms and models
- Assess internal interest and understanding of VBP
- Assess your readiness for a new or modified VBP model(s)
- Identify current data analytical capabilities and gaps
- Understand member attribution and assignment
- Understand your population and health disparities
- Understand types of financial risk in VBP models
- Get ready for VBP
- Go live with VBP model(s)
- Promote provider clinical transformation to foster VBP success
- Access technical assistance and peer learning
- Understand how quality is measured and used in different VBP models
- Maximize quality improvement – performance on measures
- Review results and make modifications
- Scale up current VBP contracts and engage additional payers
- Understand VBP compact models
- Primary care model
- Specialty care models (future content)
- Hospital care model (future content)
Once you understand your patient population and disparities, you can work with your payers to include strategies in the VBP model to promote health equity, such as:
- Equity-focused quality measures in any aligned measures set(s).
- Financial incentives for practices to stratify quality measure performance by REALD in order to identify any potential disparities and develop targeted interventions.
- Support for services such as health-related social needs (HRSN) screening and/or traditional health worker (THW) services in the prospective payment or via FFS or supplemental payments.
- Financial incentives to identify and engage people who are not accessing primary care.
- Infrastructure payments to support collaboration and data sharing between practices and social services organizations to address identified HRSNs.
- Exploration of risk adjustment methodologies that account for social risk factors
Virginia Garcia Memorial Health Center, a federally qualified health center with 18 locations serving the communities of Washington and Yamhill counties, places a special emphasis on caring for migrant and seasonal farmworkers and others with barriers to receiving health care. The health center has started collecting data on social complexity which they hope to eventually work with payers to use for social risk adjustment. The data collected through screening is coded in their EHR to better understand the needs of the population and align with social service providers.
Since 2012, OHA has contracted with Coordinated Care Organizations (CCOs) to implement delivery system transformation and payment reform through the state’s Medicaid program, including VBP. One of the objectives of the OHA VBP Roadmap for CCOs is to “ensure consideration of health disparities and members with complex needs”, noting that “VBP strategies should, on the whole, benefit members with complex health care needs and priority populations such as racial, ethnic and culturally based communities; lesbian, gay, bisexual, transgender and queer (LGBTQ) people; persons with disabilities; people with limited English proficiency; immigrants or refugees and members with complex health care needs, as well as populations at the intersections of these groups”. The VBP Roadmap for CCOs cautions that “[i]t is essential to ensure there are no negative unintended consequences of VBPs on these and other populations”.
The 2022 interim progress report noted some successes and challenges for CCOs in integrating health equity in their VBP efforts. Successes include engaging providers in reviewing community- and provider-level quality performance data, but there have been challenges in monitoring health inequities arising from VBP arrangements, with wide variation in providers’ health IT capabilities. Overall, CCOs are promoting health equity through VBPs using the following approaches:
- Quality performance measure selection and targets,
- Tiered or adjusted payments for providers,
- Identification and inclusion of eligible providers, and
- Process or attestation-based requirements in the VBP contract.
Equity also requires patients, families and caregivers who are most impacted by policies and systems have some ability to provide input to changes to health care payment and delivery. One way to do this is to create a patient and family advisory council consisting of patients and family members who have received care at your practice and administrators, clinicians, and staff.
As part of CPC+ Providence Medical Group (PMG) engaged patients and families, through patient and family advisory councils (PFACs), to participate in health care transformation to achieve higher quality and a more equitable health care delivery. The work is labor intensive and with the pandemic many PFACs stopped meeting and recruiting new members is challenging. PMG’s Patient Engagement Program Manager is working with clinics to explore other ways to engage patients.