Ensuring Equity: Addressing Disparities In Health Insurance Access Across Europe – State Medicaid agencies are beginning to use policy initiatives to address wide, well-documented disparities in health care and outcomes and address longstanding health disparities related to factors such as race, ethnicity, disability status, geography, sexual orientation, and gender identity. One potentially powerful policy driver is payment reform. Combining financial incentives and alignment with strategic efforts to move away from fee-for-service payments can help prioritize investments in health care systems and build leadership buy-in to drive more equitable care delivery.
To help payers and other stakeholders make tangible progress in this regard, the Healthcare Payment Learning and Implementation Network (LAN) recently released Advancing Health Equity Through APMs: Guidelines for Equity-Focused Design and Implementation
Ensuring Equity: Addressing Disparities In Health Insurance Access Across Europe
The guidance document, developed by LAN’s Health Equity Advisory Team, recommends changes to alternative payment models (APM) to make care more accessible and equitable, and to drive better health outcomes. It calls on public and private healthcare stakeholders to work together to implement the methods in a consistent manner.
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To help state Medicaid agencies apply the LAN guidelines and support health equity within payment reform efforts, this blog post summarizes the guidelines and describes practical steps for immediate action.
Describes a theory of change for how APMs can promote health equity (see Figure 1) and outlines methods for incorporating two specific design elements into APMs: (1) person-centred, culturally and linguistically appropriate care ; and (2) payment incentives to reduce health disparities in quality of care, outcomes and patient experience.
Source: Healthcare Payment Learning and Action Network. Promoting Health Equity Through APMs: Guidelines for Equity-Focused Design and Implementation. December 2021.
In order to promote the adoption of person-centred, culturally and linguistically appropriate models of care, the LAN recommends that public and private payers and purchasers adapt contract terms to:
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Also includes design guidance to help stakeholders tailor these contract changes to address local context and community/provider priorities. The guidelines are structured with “essential” and “enhanced” approaches for more advanced practitioners, as well as examples of how Medicaid, commercial, marketplace and Medicare payers have already adopted these recommendations. The guidelines provide suggestions for action, which emphasize partnering with communities throughout the process of incorporating these elements into APMs and developing a plan for measuring the unintended consequences of APM adoption.
State Medicaid programs typically use one of two methods to promote managed care organization (MCO) and provider adoption of value-based payment (VBP): (1) VBP adoption requirements for contracted MCOs; or (2) state-designed models in which providers participate either directly with the state or through managed care. States using either approach can begin to incorporate health equity into their APM approaches by taking the following steps in partnership with community members, providers, and MCOs:
Medicaid agencies are already using methods to promote health equity through APMs that align with LAN recommendations. For example:
As noted by the LAN, the country is at a critical time for action and making tangible progress to reduce health disparities and transform healthcare into a fairer system. Payment reform creates a practical opportunity for state Medicaid leaders to foster greater accountability for and make measurable improvements in health care quality for populations experiencing the worst health outcomes.
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Provides concrete guidance to help states and other purchasers design and implement payment methods that can move the needle. While the process of aligning stakeholders around health equity definitions, metrics, and equitable care models is not a simple endeavor, state leaders can leverage a shared commitment to health equity to accelerate this important work.
Health Matters Blog | How States and Health Plans Can Mindfully Engage Dually Eligible Individuals in Plan Governance The COVID-19 pandemic and a nationwide racial justice movement in recent years have increased the focus on health disparities and their underlying causes and contributed to the increasing prioritization of health equity. These differences are not new and reflect long-standing structural and systemic inequalities rooted in racism and discrimination. While increased efforts have recently focused on addressing disparities, it could end some policies put in place during the COVID-19 pandemic, including continuous enrollment in Medicaid and the Health Insurance Program Children (CHIP), reversing progress and widening disparities. Tackling health inequalities is not only important from an equity perspective, but also to improve the nation’s overall health and economic prosperity. This brief provides an introduction to what health and health care disparities are, why it is important to address disparities, what the status of disparities is today, recent federal actions to address disparities, and key issues related to addressing differences when looking to the future.
Health and healthcare inequalities refer to differences in health and healthcare between groups that arise from wider inequalities. There are multiple definitions of health inequalities. Healthy People 2030 defines health inequality, as “a particular type of health difference linked to social, economic and/or environmental disadvantage,” and which adversely affects groups of people who have experienced greater barriers to health systematically. The Centers for Disease Control and Prevention (CDC) defines health disparities as, “preventable differences in the burden, disease, injury, violence, or in opportunities to achieve optimal health experienced by racial groups and communities , ethnic and socially disadvantaged populations. ” Health care disparity typically refers to differences between groups in terms of health insurance, affordability, access to and use of care, and quality of care. The terms “health inequality” and “injustice” are also sometimes used to describe unjust differences. Racism, which the CDC defines as the structures, policies, practices, and norms that determine value and determine opportunities based on the way people look or the color of their skin, leads to conditions that gives an unfair advantage to some and puts others at a disadvantage, placing people of color at greater risk for poor health outcomes.
In general, health equity refers to individuals achieving their highest level of health by eliminating disparities in health and health care. Healthy People 2030 defines health equity as the attainment of the highest level of health for all and states that it requires valuing everyone equally with ongoing and focused social efforts to address avoidable inequalities, injustices historical and contemporary, and health and health care inequalities. The CDC describes health equity as when everyone has the opportunity to be as healthy as possible.
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A wide variety of factors within and beyond the healthcare system drive disparities in health and healthcare (Figure 1). Although health care is essential to health, research shows that health outcomes are driven by multiple factors, including underlying genetics, health behaviors, social and environmental factors, and access to health care. Although there is currently no consensus in the research on the size of the relative contributions of each of these factors to health, studies suggest that health behaviors and social and economic factors, often referred to as the social determinants of health, are the main drivers of health. outcomes and that social and economic factors shape individuals’ health behaviours. Furthermore, racism negatively affects mental and physical health both directly and by creating inequalities across the social determinants of health.
Health and health care disparities are often viewed through the lens of race and ethnicity, but they occur across a wide range of dimensions. For example, differences occur across socio-economic status, age, geography, language, gender, disability status, citizenship status, and sexual identity and orientation. Research also suggests that differences occur across the life course, from birth, through midlife, and among older adults. Federal efforts to reduce disparities focus on designated priority populations, including, “members of underserved communities: Black, Latino, and Native American people, Asian Americans and Pacific Islanders and other people of colour; members of religious minorities; lesbian, gay, bisexual, transgender and queer people (LGBT+); people with disabilities; people living in rural areas; and people who are otherwise adversely affected by persistent poverty or inequality.” These groups are not mutually exclusive and often intersect in meaningful ways. There are also differences within subgroups of populations. For example, there are disparities among Hispanics in health and health care based on length of time in the country, primary language, and immigration status. Data also often mask fundamental differences among subgroups within the Asian population.
Tackling disparities in health and healthcare is important not only from an equity perspective but also to improve the nation’s overall health and economic prosperity. People of color and other underserved groups experience higher rates of illness and death across a wide range of health conditions, limiting the overall health of the nation. Research also finds that health disparities are costly, resulting in excess medical care costs and lost productivity as well as additional economic losses due to premature deaths each year.
Addressing health disparities is increasingly important as the population becomes more diverse and income inequality continues to grow. People of color are predicted to make up over half (52%) of the population in 2050, with the greatest growth occurring among people who identify as Asian or Hispanic (Figure 2). Over time, the population has become increasingly racially diverse, reflecting changing immigration patterns, a growing multiracial population, as well as adjustments to how the federal Census Bureau measures race and ethnicity. Over time, income inequality in the United States has also widened. From 2021, the richest 20% of households accounted for over
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