Intention precedes implementation in health policy. This has been true for payment policy over the last decade, in which policymakers and insurers have set an intention and implemented programs to shift away from fee-for-service reimbursement toward value-based arrangements designed to reward clinicians and organizations for outcomes and cost-efficiency.
But progress in creating a value-based care culture and delivery system has not necessarily translated into progress in health equity — a critical and persistent problem in U.S. health care despite decades of evidence about how historically marginalized communities and others face disparities in care. One reason is that far too often, inequity is considered after-the-fact as an unintended consequence that leaders must monitor for in new payment and care delivery strategies, rather than as itself an explicit priority in policy design.
We believe that stakeholders across health care should set an explicit intention to use health care payment to promote equity. But translating that intention into reality comes with many unknowns. What opportunities does the health services research community have to help achieve this goal?
This a question that Joshua Liao discussed with AcademyHealth President and CEO Dr. Lisa Simpson as part of Health Equity Conversations. As one part of a broader initiative to combat inequity using health care payment, we started the Conversations podcast series to feature people and groups around the country working to improve equity by studying, advocating for, and affecting health systems change.
The conversation with Dr. Simpson examined the opportunity to create research agendas focused on the intersection of health equity and payment. As Dr. Simpson noted:
“We have not taken the time to step back and link two key concepts that existed in the initial IOM Framework for Quality and where we are today. We’ve talked a lot over the years in the payment world, about value, low value care, and high value care, and incentivizing value. And those conversations have historically been devoid of mention of equity, and hence why your work that you’re doing is so important. At the same time the work of equity has been, for decades, and it’s nuanced and rich, and it has been ongoing, but again the conversation around value in care has not come together. Now, those are two very rich bodies of evidence, but yet they’re separate.”
To contribute to change, Dr. Simpson shared about an initiative being launched through AcademyHealth via support by the Donahue Foundation to identify a research agenda to drive care that is simultaneously equitable and high value. Subsequent steps include aligning funders with different parts of that agenda to enable researchers to generate and translate evidence into policy and practice. As Dr. Simpson noted, “we cannot innovate our science without addressing equity and inclusion.”
A second, related opportunity that Drs. Simpson and Liao discussed was to foster a research community at the intersection of health equity and payment. Of course, there have been and continue to be robust research communities studying both equity and payment. But progress in each will require work in the other: it will be difficult to achieve equity without refashioning payment systems, and payment is unlikely to achieve the goal of improving health care without directly considering equity.
These steps are insufficient to combat inequity on their own. Other foundational elements such as data infrastructure and funding are pre-conditions for impactful research. The research must also move beyond observations about inequity into prospective implementation of programs designed to combat it. Even with a diverse group of stakeholders setting the agenda, scholars must work with leaders on the subsequent work of implementing evidence into real-world policy and practice.
Nonetheless, it is hard to envision progress without contributions from the health services research community, and changes in how it sets research agendas and creates community at the intersection of equity and payment. As Dr. Simpson noted, enacting changes that ultimately help the field learn from healthcare transformation and accelerate equity is an achievement she would be proud of.
We agree. In future phases of our initiative, we seek to contribute to such change by actively partnering with organizations to analyze and implement equity-based payment programs.
Listen to Health Equity Conversations and learn more here.