A Journey of Resilience and Advocacy in a Complex Health Care Landscape
April 17th, 2024
In early 2015, during a routine doctor’s appointment, David Ford’s physician recommended a colonoscopy. However, it wasn’t until three months later, when Ford, a senior government relations manager with Southern California Edison, experienced rectal bleeding on his way to work, that the urgency of his situation became apparent. An emergency surgery revealed a tumor on his intestines, leading to a diagnosis of colorectal cancer — the second leading cause of death from cancer in the United States.
Navigating the Delivery System
Ford was thrust into a challenging health care journey, facing the intricacies of cancer treatment. Navigating the health care system added another layer of complexity. Ford had to coordinate appointments across different health care providers, understand the nuances of his insurance coverage and make informed decisions about his treatment options. The difficulty of this process was exacerbated by the need to decipher medical jargon and understand the implications of different medical procedures and tests.
Throughout his treatment, Ford, a Black man, became acutely aware of the disparities in health care access and the additional challenges faced by those in minority communities. Black Americans have a 20% higher incidence of colorectal cancer and a 40% higher death rate from the disease than white Americans, underlining the urgent need for action to reduce these inequities. During a recent PBGH California Quality Collaborative (CQC) webinar that explored disparities in colorectal cancer care, Ford shared his story, recounting his delay in undergoing a colonoscopy and how his experience may have been different had he been more proactive about undergoing the screening test.
During an annual physical exam in 2018, Ford’s physician conducted a test that revealed elevated prostate-specific antigen numbers, leading to a diagnosis of prostate cancer. After undergoing radiation treatment, he was able to make a full recovery. Ford’s experience underscores the critical need for proactive health management and screening for early detection through tools such as the EpiSwitch Prostate Screening (PSE), especially in communities of color, where distrust in the health care system and barriers to accessing care are common.
A Voice for Advocacy and Change
Today, Ford serves as a member of the Cancer Action Network board, actively engaged in lobbying and advocacy efforts. His experience has fueled his commitment to cancer research, funding and policy change, making him a vocal advocate for equitable access to care.
“There’s more advocacy and education to do through outreach and connection with community-based groups, churches and national organizations to get behind this campaign because I do think that this is a civil rights crisis, particularly in the African American community,” said Ford. Ford emphasizes the importance of early detection, especially given today’s innovative technology and testing options which are less invasive and allow for greater accuracy: “Cancer is much easier to treat and deal with if it’s early… get in to see someone as soon as possible when you think something is wrong.”
Strategies to Combat Colorectal Cancer Disparities
The following key strategies can help reduce disparities in colorectal cancer care within the delivery system:
- Multi-stakeholder collaboration. Alignment among health care providers, payers, policy makers and patient advocates is essential for comprehensive care and disparity reduction.
- Patient engagement and advocacy. Engaging patients in their health care journeys, especially through preventive measures like cancer screening, is critical for early detection and treatment.
- Research and data utilization. Utilizing comprehensive data and research findings to informs policy and practice, leading to more effective screening and improved health outcomes.
- Community outreach and education. Developing community-based programs and partnerships facilitates access to screening and treatment services, building trust and awareness within communities.
CQC is working to advance health equity through programs like Equity and Quality at Independent Practices in LA County, a quality improvement collaborative for primary care practices and independent physician associations focused on reducing health disparities for Medi-Cal enrollees of color.
To learn more about disparities in colorectal cancer care and what patients, providers, health plans and purchasers can do to advance equitable care, view a recording of CQC’s latest webinar Addressing Disparities in Colorectal Cancer and access our guide to designing an effective colorectal cancer outreach campaign.
Empowering Care: The Role of Alternative Payment Model Design in Advancing Equity
January 25th, 2024
Alternative Payment Models (APMs), incentivizing clinicians to provide high-quality, cost-efficient care beyond traditional fee-for-service payments, hold immense potential to revolutionize health care delivery, expanding access, improving outcomes and addressing health disparities. However, to unleash their transformative power, APMs must be thoughtfully designed to prioritize health equity and mitigate unintended negative consequences. Factors such as poverty, institutional racism, education, economic opportunities, insurance coverage and the living environment significantly influence health equity. When capitated payments and performance incentives fail to account for the necessary resources to provide adequate care, practices serving populations with higher medical and social risks may face financial challenges, ultimately impacting health outcomes negatively.
Multi-Stakeholder Alignment
Multi-stakeholder collaboration is pivotal in aligning the design and implementation of a payment model that champions health equity. Through the California Advanced Primary Care Initiative, PBGH’s California Quality Collaborative (CQC) and partner Integrated Healthcare Association (IHA) bring together health care payers to collectively strengthen primary care delivery. The initiative aims to facilitate the delivery of high-performing, value-based care, reducing costs while enhancing quality and equity. CQC and IHA collaborated with health plans to develop a common hybrid primary care payment model, incorporating key recommendations from subject matter experts in payment model design and health equity intended to strengthen health equity in APM design and implementation, regardless of geography. The payment model is comprised of three key elements: direct patient care payment, population health payment and performance-based payment.
Recommendations to Advance Equity
Element 1: Direct Patient Care Payment
- Transition from fee-for-service (FFS) to capitated payments. Health Plans and other stakeholders working to develop APMs should consider gradually transitioning from FFS to capitated payments to provide upfront funding for clinical services and key staff roles, addressing social factors influencing health and advancing equity. Incremental approaches, such as phased strategies and tracking provider preferences, can facilitate a smooth transition.
- Incorporate risk adjustments for PMPM. Adopt risk adjustment into APM contracts, acknowledging the underlying clinical and social risk of the population. This ensures that reimbursements account for higher-risk populations, recognizing the need for additional resources to eliminate health inequities. Clear goals and method determination are essential in building an effective risk adjustment strategy.
Element 2: Population Health Management Payment
- Incorporate a distinct population health management payment. Separating the population health management payment from patient care payments supports practice improvement, especially for historically under-resourced providers serving populations experiencing health inequities. Payments can be tied to specific activities, with requirements related to the promotion of health equity, fostering targeted interventions and support.
- Provide technical assistance. Effective technical assistance should be offered to providers, encompassing guidance and support for culturally and linguistically appropriate quality improvement interventions. Tailored technical assistance can facilitate the integration of community-based providers, ensuring alignment with health equity goals.
Element 3: Performance-Based Payment
- Weight quality-based payments to equitable health outcomes. Develop financial incentives that meaningfully reward the reduction of health disparities and promote equitable health outcomes. Establish improvement and attainment goals with expectations for data stratification by race and ethnicity. Incentives should align with measures required to be stratified by national and state governing bodies, fostering a focus on equity performance.
APMs, with intentional design considerations for health equity, can uniquely contribute to addressing health disparities. Direct investments and dedicated support are crucial elements, ensuring that practices serving rural or underserved areas have a viable path to success within the payment model. Multi-stakeholder alignment and ongoing collaboration are key to driving cooperative changes and improving the delivery of care. The journey toward APMs requires collective efforts and guidance from diverse stakeholders, from payers and providers to community-based organizations and those receiving care.
For a more detailed look at the recommendations, read our latest issue brief.
Advanced Primary Care Key to Reducing Health Inequities
June 14th, 2023
Robust, comprehensive primary care – a critical foundation for a more cost-effective, high-functioning health system – is equally important in helping boost health equity, a new report states.
The report, produced by the California Health Care Foundation, underscores the variety of ways in which advanced primary care can advance equity in care access and quality for underserved populations. Yet it also warns of significant barriers that continue to thwart primary care’s potential in California and nationwide.
In the face of these obstacles, employers can take steps today to strengthen primary care and reduce health care inequities. Actions can include expanding primary care locations, pushing insurers to strengthen financial support for primary care and increasing telehealth capabilities.
Unlocking Health Equity through Advanced Primary Care
Long-standing racial and economic discrimination in health and social policy has fostered pervasive health gaps for people of color. These disparities range from greater disease burdens and more mental health problems for racially minoritized populations to increased mortality and shorter life expectancies. Historically marginalized racial and ethnic groups also contend with less insurance coverage and reduced access to care.
The good news is that the key components of advanced primary care are particularly well-suited for reversing systemic health care inequities, according to the California Health Care Foundation report. Primary care’s capabilities and resulting benefits include:
- Improved access: A higher density of primary care physicians has been repeatedly linked to increased preventive services, lower avoidable morbidity and mortality and longer life expectancy among Black populations. Increasing the supply of diverse primary care doctors also helps reduce racial disparities in referral patterns and increases needed hospital care for Black Americans.
- Improved care continuity: Ongoing, individualized care provided by a single primary care clinician or practice is tied to lower mortality rates and fewer disparities in receiving recommended cancer screenings among Black and Latino populations. Interpersonal continuity with a primary care practitioner likewise enhances patient trust, which translates into better adherence to recommended preventive services, treatments and medications.
- Better coordination of care: Continuity across provider types and health care settings is shown to reduce racial and ethnic inequities in many important areas, including preventable emergency department visits and improved blood pressure control. For patients with multiple chronic conditions, coordination also lessens the burden of interacting with a fragmented and disorganized care system.
- Greater comprehensiveness: Integrating behavioral health and primary care services is considered one of the most effective ways to improve mental and physical health outcomes while eliminating inequities in care quality and access for racial and ethnic minority populations.
- Whole-person orientation: Elements of accountable, whole-person care — including clinician knowledge of a person’s overall medical history, social needs, preferences, family and cultural beliefs — improves patient self-management for chronic conditions. This is important for patients from racially and ethnically minoritized groups, who are more likely to suffer from complex comorbidities.
Advanced primary care’s power to mitigate health inequities highlights the wider benefits it can produce. Adults who regularly see a primary care physician have 33% lower health care costs and reduced odds of dying prematurely than those who see only a specialist. Every $1 increase in primary care spending produces $13 in savings.
Despite these critical advantages, primary care remains woefully under-resourced, accounting for 35% of health care visits yet only receiving 5.4% of all spending on health care in the U.S. Reimbursement for Medicaid services for low-income, at-risk populations is significantly less than Medicare and commercial rates. As a result, many young doctors burdened with student debt opt for better-paying specialties, exacerbating an already severe primary care clinician shortage.
Employers Can Take Steps to Bolster Primary Care and Advance Health Equity
Notwithstanding these challenges, employers can take steps today to accelerate advanced primary care to help reverse inequities and improve overall employee health, including:
- Increasing the overall proportion of funds dedicated to primary care. Ask your health plan what percentage of spending currently goes to primary care and work to develop incremental increases over time. To track health plan performance over time and hold plans accountable for performance, more than two dozen members of the Purchaser Business Group on Health have signed onto a first-of-its-kind tool called the Health Value Index, which creates actionable insight into a purchaser’s health plan spending and incentivizes both short- and long-term improvements in care for participating companies’ employees.
- Request data on self-identified race and ethnicity, sexual orientation, gender identity, language preference and disability status: Ask providers and plans to report their REaL (Race, Ethnicity and Language) and SOGI (Sexual Orientation and Gender Identity) data and to identify how they’re working to address health care inequities. With this data you can also begin to identify gaps in equity among your employees and families. Some easy places to start is stratifying primary care spend and use of a primary care clinician by REAL and SOGI data to identify gaps to focus on within plan design. This work is difficult, so it could require engaging with experts to help you develop and apply a shared structural understanding of racial inequities to ensure that your team is generating accurate, helpful and actionable insights from data analysis.
- Ensuring access to telehealth that is coordinated with primary care. Telehealth has emerged as a critical tool for advancing health equity by increasing access for underserved populations. Employers should ensure that telehealth services are available for employees, as well as go one step further by working with vendors to ensure that telehealth services are coordinated with the employee’s primary care physician. When telehealth is a service provided by the primary care clinician, this coordination is already in place, however there are many third-party vendors offering telehealth services and employers should be thoughtful in terms of mitigating the risk of creating a two-tiered system that contributes to fragmentation of care.
- Adopting a holistic approach to employee health benefits. Employers should work with their plans to ensure collection and identification of social risk factors and needs that could be affecting their employee population. This would allow for holistic benefits design that could provide assistance to employees with addressing social needs that can have negative, long-term impacts on employee health.
- Ensuring adequate mental health resources. Ideally, behavioral health capabilities should be integrated with primary care to increase access and whole-person care. Setting this expectation for health plans and providers as a purchaser, as well as increasing investment into primary care to ensure these services can be funded, will help ensure these resources are prioritized and funded.
- Expanding after-hours primary care access. There are multiple models supporting after-hours care, including use of telemedicine or expanding clinic hours. Ultimately, purchasers must champion payment reform that will make these types of services possible. Much like with mental health, employers can support this conversation by also highlighting after-hours primary care access as an expectation that this is a part of critical infrastructure and including it in the purchase and payment of services.
Transforming Health Care Through Primary Care
Given advanced primary care’s unmatched ability to both address inequity and transform our health system, consensus is building around efforts to overcome longstanding financial barriers and dramatically strengthen the nation’s primary care infrastructure.
The California Health Care Foundation report, for example, calls for a new paradigm that includes programs to increase recruiting and training of primary care physicians, increased primary care spending, improved Medicaid reimbursement and expanded primary care hours and locations. Employers can play an essential role in pushing payers to invest in primary care, as well as encourage providers to use the investment to realize and extend the many benefits advanced primary care offers.
Ultimately, it is about increasing equal access to high-quality primary care for all. Having access is equity.
Special thanks to Rishi Manchanda, M.D., co-author of the CHCF report.
Maternity Deserts an Alarming Trend in the U.S.
May 1st, 2023
Maternity units across the country continue to close at increasing rates, leaving women at a heightened risk of maternal mortality. In fact, 47% of rural community hospitals report having no obstetric services in 2020. According to a report by the March of Dimes, more than 2.2 million women of childbearing age live in maternity care deserts, affecting nearly 150,000 babies.
Maternity care deserts are counties in which access to maternity health care services is limited or absent, either through lack of services or barriers to a woman’s ability to access that care. Living in a maternity care desert contributes significantly to a woman’s risk of maternal mortality. Studies show that this risk is even higher for women in rural areas, who have fewer options for prenatal care and fewer health care providers available to deliver their babies. This creates longer wait times and longer travel times to seek care.
The reasons behind these closures are complex, but many hospitals with obstetrics units are closing due to financial pressures, such as low reimbursement rates and high malpractice insurance costs. Additionally, the aging population of health care providers, particularly among obstetricians and midwives, creates additional challenges for rural communities. This results in fewer obstetricians and midwives available to provide prenatal care and deliver babies.
What’s the Solution?
Intervention from policymakers, including legislation, may be necessary to address the underlying causes of maternity deserts. Policy efforts should focus on ensuring all women have access to quality prenatal care and a safe environment for delivering their babies. Federal and state governments can invest in programs to recruit and retain physicians and midwives in rural areas, and the root causes of these closures can be addressed by offering financial incentives, such as loan forgiveness and tax incentives, to hospitals that offer obstetric services.
Several state Medicaid programs and major health systems in New Mexico, Missouri and Utah are leveraging telemedicine and remote monitoring and developing hub and spoke models of care in which obstetricians or maternal fetal medicine specialists in urban areas provide education and support to rural providers, who are more likely to be family medicine physicians and nurse practitioners than obstetricians.
Since obstetric unit closures in rural hospitals are often due to inadequate payments from private insurers, it’s time to rethink the way we pay for maternity care in these settings. The Center for Healthcare Quality and Payment Reform has proposed a new strategy which could create sweeping change – paying rural hospitals a monthly fee for each insured woman of childbearing age in the community, in addition to paying service-based fees directly related to pregnancy, delivery and postpartum.
Employers also have a critical role to play and know that improving maternal health outcomes in the U.S. and reducing disparities will require changes to the existing system of care to make it more patient-centered.
Here’s what employers can do to mitigate the trend of increased maternity deserts:
- Benefit design: Ensure employees have access to and coverage for community models of perinatal care, including midwives and birth centers. Evidence shows freestanding birth centers in rural communities offer a safe and local alternative for high-quality maternity care, rather than pregnant women having to drive long distances for labor and birth. For example, employers can cover out-of-network midwives and birth centers at in-network rates to improve access to community providers.
- Payment models: Paying for maternity care in one bundled payment encourages high-value maternity care by utilizing midwives, reducing unnecessary interventions such as C-sections and increasing maternal mental health screening in the prenatal period. When all providers, including the facility, are operating under a single budget, they are incentivized to coordinate care, increase efficiency and choose care delivery options that offer the best outcome for the patient’s health and experience. Purchasers can also consider paying rural hospitals a standby capacity payment in addition to service-based fees.
- Contracting standards and accountability: Employers can work in coordination to develop common standards, measures and purchasing principles. This set of tools could be used in contracting with health plans and providers to ensure high-quality, affordable and equitable maternity care. The PBGH Comprehensive Maternity Care Workgroup has begun this work. Employers and public purchasers interested in joining this effort can reach out to Blair Dudley.
Read more about employer strategies to promote high-value maternity care.
A Vicious Circle: Food Insecurity Both a Cause and Effect of Higher Health Care Costs
February 23rd, 2023
More than 34 million people, including nine million children, lack reliable access to enough food to live active, healthy lives. Grinding inflation and rising health care costs are making life even more difficult for food-insecure Americans – undermining health and forcing risky tradeoffs between sustenance and medical care.
Factors contributing to food insecurity include poverty, a lack of affordable housing, racial discrimination, chronic health conditions and poor health care access.
Fueling Higher Costs
As a major social determinant of health, food insecurity contributes to chronic diseases like obesity, heart disease and diabetes. For children, food insecurity and chronic hunger create a higher risk of both developmental and behavioral health problems.
A 2019 study by Feeding America estimated that food insecurity costs the U.S. health care system an additional $53 billion annually by triggering or exacerbating chronic diseases and fueling emergency room visits, hospitalizations and readmissions.
It also results in higher family health care expenditures. A recent study found that food-insecure families paid about 20% – an average of $2,500 – more annually in health care costs than families with sufficient food.
Health care costs were higher regardless of the type of health care coverage the family had, from $1,855 more with public insurance and $2,107 more with private insurance to $3,531 more with no insurance or a mix of different coverages.
Choosing Between Food and Care
For many living near or below the poverty line, inflation’s steep rise over the past two years has led to increasingly difficult choices between food and health care. According to a recent survey conducted by the Harris Poll, nearly one-in-five Americans (18%) have skipped meals or did not buy groceries due to high inflation (including 28% of Gen Z and 23% of millennials).
At the same time, 14% have cancelled or postponed plans to see a medical specialist, 11% have skipped an annual physical, and 10% have not taken prescribed medication due to inflation.
Minorities, Single Moms Disproportionately Affected
Food insecurity affects a little over 10% of U.S. households, according to the USDA. However, rates among single-mom households and Black and Hispanic households are substantially higher than the national average at 24%, 20% and 16%, respectively. Rates also differ significantly from state to state due to population characteristics, governmental policies and economic conditions. Between 2019 and 2021, food insecurity rates ranged from a low of 5.4% of households in New Hampshire to a high of 15.3% in Mississippi.
Food insecurity needs to be a bigger part of the conversation around health equity and efforts to decrease health disparities. As employers, purchasers and policymakers continue to navigate and combat ever-rising health care costs in this country, it’s important to remember that there are working Americans who must choose between putting food on the table and getting necessary medical care and prescription drugs.
4 Key Employer Health Trends for 2023
January 4th, 2023
With the pandemic’s grip finally easing, employers are shifting their focus toward key objectives that can support sustained improvements in health care quality and meaningful reductions in cost. Here, the top four trends for large health care purchasers to watch as we head into 2023.
1. Improving health equity
COVID-19 exposed major disparities in the U.S. health care system and helped fuel an employer commitment to tackle the systemic inequities faced by underserved and minority communities. Employers understand that by focusing on health plan design, care access and social determinants of care, they can make important strides toward providing more equitable and cost-effective care.
In the coming year, more large companies will be looking to cover preventive medications and services, supporting pregnancies through doula services, developing data capabilities to identify and help address social determinants, improving remote chronic disease management, and making benefits and health care simpler to access and navigate for underserved populations.
2. Strengthening primary care
Employers realize that robust primary care provides the foundation for a healthy workforce and is an essential starting point of high-value health care system. Studies show that advanced primary care, or primary care systems that incentivize integrated and coordinated care, can lower overall health utilization, improve outcomes and reduce costs.
Key strategies employers are expected to target to bolster primary care include supporting consistent advanced primary care standards for payers, providers and health care purchasers to incentivize high-quality, lower-cost primary care. Other employer efforts are likely to focus on working with policymakers to advance the development and application of alternative payment models that support and enable advanced primary care. Equally important will be the continued evolution of tools and systems that enhance consistent access to behavioral mental health in the primary care setting.
To support purchasers in their efforts to identify and work with top-performing primary care practices, PBGH recently issued a first-of-its-kind collective request for information (RFI) on behalf of members to identify provider practices that meet established standards of advanced primary care and that are willing to partner — the results of which will be used in network design and/or in direct contracting arrangements.
3. Taking fiduciary responsibility for health care
The Consolidated Appropriations Act (CAA) of 2021 imposes fiduciary obligations for employers who self-insure under the Employee Retirement Income Security Act of 1974 (ERISA). That means self-insured employers will need to demonstrate that the health care services they purchase for employees are cost-effective and high-quality. As a result, employers will be working to harness newly available hospital price information to drive cost-effective, quality care. Critical to these efforts will be tools that can make newly transparent price data meaningful and actionable. In addition, collective employer efforts to identify specific examples of overpricing will likely emerge to support negotiating leverage with hospitals and providers. Ultimately, employers’ new fiduciary obligations may spawn a shared national database with companion analytics that purchasers can use for evaluating pricing variation to help determine fair prices.
4. Reforming pharmacy benefit managers (PBMs)
A key legislative objective for purchasers in 2023 will be passage of legislation similar to the last Congress’s Pharmacy Benefit Manager Transparency Act of 2022. Comprehensive federal legislation would empower the Federal Trade Commission to increase drug pricing transparency and hold PBMs accountable for numerous unfair and deceptive practices that increase consumer costs and limit access of prescription drugs. In addition to expected action from Congress, a Federal Trade Commission investigation into PBM business practices is underway. Employers, meanwhile, will increasingly be looking to new market entrants that promise more transparent PBM services and put employers in control of their data to gain greater control over rising drug costs and employee access to quality care. PBGH is working across multiple channels to raise awareness about the extent to which PBMs have distorted the prescription drug supply chain – actions which put lives at risk, constrain employee access to medications and add billions of unnecessary costs to employers’ health care expenses.
Better Data Collection Essential to Understanding and Addressing Health Inequities
December 14th, 2022
The COVID-19 pandemic exposed and exacerbated the weaknesses of the U.S. health care system and highlighted long-standing inequities for minority communities. Highlighted during this period was the profound impact of economic stability, education, social and community life, one’s neighborhood and access to high-quality health care—social determinants of health—on the overall health and well-being of communities.
As a result, addressing health inequities has become a top priority for many employers, purchasers and health care providers. The ability to effectively collect a range of data points about patients and the care they receive is an essential component to creating meaningful change and ensuring populations achieve their full health potential.
Looking at health quality data by race, ethnicity, language and other patient characteristics, is crucial for understanding how long-standing systems of privilege and oppression impact the health of minority populations and communities. However, patient self-reported race, ethnicity and language (REaL) data across health insurance markets is widely variable and overall limited. While race and ethnicity data in California’s Medicaid program (called Medi-Cal) is broadly available likely because of legislation requiring health plans to collect this information starting in 2009, corresponding data for the majority of patients who receive health benefits through the commercial market – via employers or on the private market –is low or absent.
These limitations of known race and ethnicity data hinder the ability to see where disparities exist and for the health system to react with meaningful interventions. For health plans and large employers and purchasers, who provide health benefits for more than half the U.S., it is crucial to uncover variation in the access to care and the quality and experience of care being provided.
With better self-reported patient demographic information, employers, purchasers, payers and providers can tie this data to health care access, quality, patient experience and outcomes to illuminate exactly where disparities exist. These insights can enable tailored interventions and support for improvement.
How to Improve Data Collection
Legislation, Policy and Regulation
Legislation and regulations can incentivize or require health plans, providers and other health system organizations to increase the collection and quality of self-reported demographic data. Legislation and statute also have the potential to enforce standardization for data fields and definitions, which enables largescale purchasers of health care to align with their health plan and provider industry partners and enhance their ability to share, aggregate or disaggregate data to identify trends and implement plans for improvement.
It is crucial to ensure that national and state standards do not contradict each other.
Contracting and Business Relationships
Contracting requirements and incentives as part of large-scale public and private purchaser and payer programs can increase the collection, reporting and use of REaL data and thereby bolster efforts to mitigate disparities. Large purchasers could add incentive payouts if plans are able to stratify measures across self-reported REaL data. Health plans, provider organizations and other payers that contract within the health system can use incentive payouts for better data collection and stratification and other efforts to reduce disparities. Another approach is to build tiered networks that point patients to providers who have proven to be stronger at collecting, reporting and using REaL data.
It is important for purchasers and payers to avoid siloed initiatives that conflict with each other.
Organizational Leadership, Systems Structure and Culture
Organizations that pay for services at the point of care (e.g., health plans and independent physician associations, or IPAs) have the potential to increase REaL data collection, reporting and use by assessing and enhancing data collection opportunities, sharing data internally and creating a culture that values the collection of this information. This starts with organizational leadership. It is important to normalize data collection into regular workflows to improve the quality and ensure the most accurate information possible.
Purchasers, health plans and provider organizations can increase patient self-reporting by increasing awareness of how the data will be used and educating enrollment counselors and other staff with direct patient interaction on why it is important to collect this data.
Certification Requirements
The National Committee for Quality Assurance (NCQA) has required plans to report their percentage of self-reported REaL data for certain key measures, with a goal of 80% self-reported data. Additional accrediting organizations, purchasers and others could adopt similar certification requirements to support reporting and stratification for the same measures and self-reported data goals as NCQA. This would increase the consequences for not aligning and support the overall goal of greater availability of self-reported REaL data.
Read more in our latest issue brief.
Looking Toward the Horizon: Top 7 Health Care Trends for Employers in 2022
January 6th, 2022
At the recent PBGH year-end roundtable, noted health care futurist Ian Morrison discussed key health care trends that both he and PBGH believe will be most relevant to purchasers in the year ahead. Morrison is the author of several books on health care and has worked with more than 100 Fortune 500 companies in health care, manufacturing, information technology and financial services.
Here, the top 7 trends for large health care purchasers to watch as we head into 2022.
1. The workforce will remain in upheaval
Providers and other employers continue to grapple with the unfolding impact of the Great Resignation. Difficulty recruiting and retaining staff will remain an ongoing problem for many provider organizations. One consequence will be the continued ascendance of telehealth and other virtual care services. Separately, the loss of employer-based insurance for many workers who’ve left their jobs will likely increase self-pay, health exchange and Medicaid patients, resulting in a worsening payer mix and continued financial pressure on providers.
2. Providers depend on employers for profits
According to a recent RAND study, hospitals charge employers, on average, about 250% of Medicare rates. The premium over Medicare can range for 130% in Iowa to 300% in California. The reality is that providers are dependent on self-insured and commercial payers for their entire margin; purchasers that can’t or won’t consider shifting provider networks to compel some level of competition will continue to be subjected to the highest charges.
3. Choice has been conflated with quality
Employers are beginning to understand that in opting for broad, open provider networks over the years, they’ve undermined their own ability to direct employees and members to the highest-quality, most efficient provider organizations. This recognition is supported by surveys that show consumers themselves are willing to trade choice for quality.
That’s why, increasingly, large employers/purchasers are measuring and contracting with teams and individuals that meet their standards for quality and service and respond to their concerns, stepping away from one-size-fits-all arrangements with large health systems. PBGH members, for example, report quantified success through direct purchasing relationships with systems that are eager to innovate and demonstrate quality. Passively accepting health plan reports is a thing of the past as employers gain the experience and data needed to scale new approaches.
4. Consolidation will continue
Mergers and acquisitions across all levels of health care will continue as organizations negatively impacted by the pandemic are picked up by those interested in broadening their footprint or extending vertical integration. This trend will increase the market share of the most powerful health systems and reduce potentially more cost-effective alternatives for purchasers.
5. Investment in digital point solutions will keep growing
Venture capital investment in digital health solutions has doubled over the past several years to approximately $14.7 billion this year, and the trend is expected to continue. Fundamental questions remain about whether these solutions are truly adding value or simply increasing fragmentation and cost across the system. Employers are overwhelmed by the sales pitches they receive from new companies vying for their business and are looking for trusted sources that use clinical rigor and data-based outcomes to help them assess their value and create needed standards in the market for new entrants.
6. Addressing the health care inequities exposed by the pandemic will become a priority for providers and purchasers alike
The risks of hospitalization and death for marginalized people in the U.S. are two-to-three times higher than for white people. Organizations will continue looking for opportunities to close this gap by improving access and finding innovative ways to address social determinants of health. Such efforts can include innovative maternity care that reduces disparities and improves quality and outcomes and the broad adoption of patient-reported outcomes, which offer an ideal means for gaining insight into the care process and how its experienced by patients.
7. Employers have an historic opportunity to impose greater control over the health care supply chain
Because the pandemic has caused significant upheaval across the health care system and created financial stress for many provider organizations, purchasers have an unprecedented opening to leverage their buying power in pursuit of higher-quality, lower-cost care. However, they can have an impact only if they’re willing to act in concert. Alignment on priorities and implementation is critical to advancing the change we need. Purchasers must become more aggressive in designing benefits that favor high-value delivery partners.
Opportunities in COVID-19 Vaccine Access and Equity
May 4th, 2021
While COVID-19 vaccine eligibility has expanded and supply has increased, data show that access to vaccines are not equitable throughout California’s communities.
Health care leaders are looking to work together differently as their vaccination efforts shift from trying to meet demand through mass vaccination sites to targeted interventions that address the needs and concerns of high-risk communities and vaccine-hesitant individuals.
In late April, PBGH’s California Quality Collaborative (CQC) hosted a closed roundtable discussion for health plans, provider groups and California state agency representatives to discuss challenges and success stories in their efforts to distribute COVID-19 vaccines and support equitable vaccine distribution for under-resourced populations. Five key actions stakeholders need to take emerged from the conversation:
1. Invest internally in policies supporting equity. During the past year, many organizations worked to improve internal processes that would better enable them to serve the diverse needs of their members and staff. L.A. Care Health Plan, the nation’s largest public health plan with nearly 2.2 million members, for example, developed a set of more robust internal policies to address diversity and inclusion, as well as programs designed to minimize barriers in working with minority or women-owned businesses, an approach described in the Clinical Improvement Network Connections spring 2021 publication.
2. Facilitate real-time data sharing. All groups agreed that, while there had been investments in data-sharing that facilitated collaboration to distribute and ensure access to vaccines, there were still gaps between health care delivery systems, public health and community-based organizations in terms of the accuracy of, and timeliness with which, essential clinical data was shared. As we begin to recover from the pandemic work should be done to ensure real-time data-sharing, especially between the California Immunization Registry and health information exchanges and organizations not traditionally part of health care information exchanges.
3. Provide clear, consistent and trusted communication. It was extremely important for all entities to streamline, test and regularly deliver communications campaigns to stakeholders, including community members, provider groups and member patients.
4. Leverage trusted relationships from primary care providers. Primary care providers were unable to play a significant role in the early days of vaccine distribution, often because mass vaccination sites were prioritized so individual practices received limited vaccine supply or were unprepared to accommodate the stringent storage requirements. With vaccine distribution having stabilized, there is an opportunity to tap into the primary care provider community, which is positioned to leverage long-standing patient relationships and play an important role in vaccination efforts. Increasing primary care’s role in COVID-19 vaccine administration may prove extremely effective in reaching vaccine-hesitant or skeptical patients.
5. Sustain new and strengthened partnerships. Overall, there was a recognition that the public health emergency and response has illuminated how effective cross-sector collaboration between health plans, public health departments, provider groups and community-based organizations can be at solving urgent problems when working together. Now, there is a question about how partnering groups can continue to collaborate while finding ways to become more efficient.
COVID-19 Vaccine Resources
Addressing Social Determinants of Health Essential to Reining in Health Care Costs
January 11th, 2021
Health care’s exorbitant costs can never be controlled without fundamentally shifting society’s focus toward the underlying social and economic conditions that disproportionately contribute to ill-health. That was the message former Centers for Medicare and Medicaid Services (CMS) Administrator Donald Berwick gave to large employer members of the Pacific Business Group on Health (PBGH) during a January 7 webinar.
“I’ve lost patience with marginal change. I don’t think it’s going to work,” said Berwick, a pediatrician who led CMS for a year-and-a-half during the Obama administration and who has been a leading voice for health care reform for over four decades. “We continue to confiscate resources in health care that we don’t deserve and aren’t using properly from other sectors that badly need those resources. It’s time for some big thinking.”
The Shadow of Racism and Poverty
In a presentation subtitled “The Moral Determinants of Health,” Berwick hammered home the need to tackle systemic issues like disparities in income, education, food access, housing security and community structure. He pointed to extensive and long-standing evidence showing the outsized impact these factors have on care access, outcomes, health status and ultimately, cost.
In one example, Berwick noted that individuals who’ve been subjected to at least four adverse childhood experiences (ACE) face dramatically higher risks for nine out the top 10 leading causes of death in the U.S. They’re also 10 times more likely to experience mental illness and 11 times more likely to suffer from Alzheimer’s disease, he said. ACEs can include experiencing violence, abuse or neglect, witnessing violence, or living in a household with substance misuse, mental health problems or parental separation due to incarceration.
The COVID-19 pandemic has both exposed and exacerbated the country’s long-standing health inequities, he noted, particularly as they relate to people of color, with black Americans dying of the virus at a rate three-to-four times higher than whites.
‘Fixing the Road’
According to Berwick, unless efforts are made to move upstream to address social and economic challenges and reallocate a portion of the dollars now flowing into health care toward housing, education, food, criminal justice reform and the like, rising costs and widening disparities will continue to be hallmarks of the U.S. health system.
Berwick went on to outline his personal vision for health care transformation in the U.S., components of which include making health care universally available. He also stressed other priorities, such as ending hunger and homelessness, restoring American leadership on climate change and restoring the credibility of democratic institutions.
He noted that PBGH has been an “extremely important force and presence” in efforts to reform health care for decades and applauded the organization’s willingness to engage seriously in pursuit of solutions. Nonetheless, he said, employers generally have largely remained “bystanders” in efforts to address the social determinants of health and challenged purchasers to consider how they can affect change.
“You’re concerned about your health care costs as an employer and the costs for your employees, so connect the dots,” he said. “With 18% of our GDP and $3.5 trillion a year, health care is running a repair shop. But nobody’s fixing the road.”
The webinar, which includes a panel of health care purchasers sharing their organizations’ approach to addressing social determinants of health can be viewed in full below.
Presentation