How payers can drive collaboration to support health equity

Every stakeholder and policymaker in the healthcare system needs to support the highest level of health for all. This includes health plans, which play a vital role in driving health equity to better serve historically disadvantaged communities, focusing on the patient first and foremost. In fact, social determinants of health (SDoH) including social and economic factors, health behaviors, and physical environment may account for up to 80% of a person’s health, while only 20% is determined by genes, biology, and clinical care delivered.

For health plans dedicated to advancing equitable healthcare outcomes, here are three strategies to consider.

First, problems causing health inequities must be recognized and identified through data analytics.

Focus on the incidence and prevalence of diseases across populations and the patterns in these disease rates. Plans can accomplish this by reviewing data from traditional sources such as medical claims and coupling these results with data from other sources such as census and screening data, self-reported outcomes, and surveys. With this comprehensive picture, health plans can identify and analyze trends that demand attention.

Consider this three-step approach:

• Start with low-hanging fruit: your quality outcomes data such as HEDIS^® and Star Ratings. Examine where gaps exist and share these findings across all stakeholders. This is easier for plans that utilize integrated quality reporting and population health solutions, such as Cotiviti’s Quality Intelligence and Medical Intelligence.
• Next, stratify under-resourced members using data on conditions, procedure, diagnosis, and risk severity. Risk stratification solutions such as Cotiviti’s DxCG Intelligence are helpful in overlaying clinical classification with SDoH factors to target the most pressing disparities.
• Once you’ve stratified your members and prioritized care caps, focus on engagement, leveraging a multi-channel approach to communications to reach both members and providers. Clients using Cotiviti’s consumer engagement solution, Eliza^®, leverage quality outcomes data to create targeted outreach that approaches members with curated messaging for better comprehension and engagement. On the provider side, Cotiviti’s Network Intelligence solution identifies low-value care and helps payers develop strategies to educate and incentivize providers to participate in alternative payment models that focus on quality over quantity.

Keep in mind that not all data is properly captured or analyzed. Often, data is not uniformly collected or standardized. While data is essential for identifying where disparities exist, selection bias, contradictory data elements, or lack of trust can skew results. For example, data elements such as sexual orientation and gender identity are not uniformly collected across the healthcare landscape, or there may be significant variation in how demographic questions are asked by providers.

To address the data issue, the National Committee for Quality Assurance (NCQA) began rolling out quality measures stratified by race and ethnicity in measurement year (MY) 2022, and increased the number of measures supporting race and ethnicity stratifications from five in MY 2022 to 13 in MY 2023. NCQA is also offering a Health Equity accreditation program, with the goal of advancing health equity by leveraging HEDIS to hold health plans accountable for disparities in care among their patient populations. This includes bringing transparency to where gaps exist (or do not exist) and highlighting plans that successfully invest in strategies to reduce disparities in care and outcomes.

By advancing data standards and interoperability, plans can streamline data collection and better identify healthcare inequities from the data. As plans start to build their data analyses, these insights may be used to tailor specific interventions and address disparities once identified.

Building trust with members is also vital for health plans to collect SDoH data. If a member does not have a meaningful connection with their plan or is not confident that the plan is truly invested in their wellbeing, they might not be willing to answer a survey that could capture valuable information about how to better serve their needs. Creating this connection with members requires going beyond simply performing outreach across different channels and translating member communications into different languages. Plans must also communicate with empathy and adapt their messages to the different cultures of their member populations in order to build the trust needed to capture their members’ complete health status.

Second, plans must set goals and measure their progress.

After obtaining accurate data, plans can learn about social, economic, and environmental challenges that were identified in the data and find ways to address them while continually measuring progress. In both identifying goals and developing strategies, plans should determine how they can work with providers and patients to address those areas.

As discussed in a recent webinar, Healthfirst applied these techniques by building a model with aligned incentives between the plan and providers. While most healthcare is paid for on a fee-for-service basis, Healthfirst’s business model is unique in that close to 80% of its revenue is spent on a value-based arrangement, where participating physicians and hospitals get paid for value and member outcomes—as opposed to transactional fees and daily patient visits. Its business model focuses on creating population health outcomes and programs based on whether the member gets the care that they need.

Healthfirst believes that this model drives all participants to think about barriers and SDoH that that may impact members’ care, and how all stakeholders can drive health equity by putting the responsibility on all to solve together.

Finally, plans must work with outside organizations to drive greater health equity.

Everyone in the healthcare continuum is responsible for addressing SDoH to improve health outcomes and address quality disparities. This includes providers, employers, health plans, local governments, regulators, and other organizations seeking healthcare innovation partnerships.

Across the industry, regulatory agencies as well as policy research and payer coalitions are forming bold agendas to tackle inequities in healthcare. For example, CMS recently issued a strategic plan that introduces sweeping changes to address health equity and build these concepts into its core functions. The Blue Cross Blue Shield Association released a call to action for the adoption of industry standards that create greater efficiency and use of health equity data to accelerate the development of meaningful strategies that address disparities in care.

Plans and health systems also have an opportunity to tackle health inequities through the assessment and incorporation of nonmedical signs into patient care practices as well as partnership with community organizations and other service providers. One such partnership is a collaboration between CVS Health and Uber Health aimed at providing medical transportation in specific under-resourced communities. By focusing on the major non-medical factors that can impede members from receiving medical care, payers and providers can make meaningful progress in reducing health disparities.

What does this all look like in practice?

As pressures such as COVID-19 and provider burnout continue to place heavier burdens on the healthcare system, we cannot forget to also address health inequity, which is only amplified by other societal burdens. Healthcare data and analytics can give healthcare payers and providers the deeper understanding needed to respond to inequities. By analyzing individual, group, and population data, payers and providers may be able to better identify and respond to health disparities. And then, through goal setting and collaboration, they can improve healthcare services, member engagement, and patient outcomes. 

 HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).