VALUE-BASED CARE · ALTERNATIVE PAYMENT MODELS
their equity improvement initiatives to all of their patients - even those whose health plans have not yet introduced financial incentives linked to health equity.” Recently, Healthcare Innovation Editor-
in-Chief Mark Hagland interviewed Friedberg regarding this groundbreaking initiative. Below are excerpts from that interview.
In this value-based contracting work, what is BCBSMA’s core overall strategy? Our overall strategy includes four main pillars: to make sure our members receive high-quality, affordable, equitable care, with an excellent consumer experience. And we added that equity pillar in the middle of 2020. Quality had always been a pillar, per the Institute of Medicine. But we decided to explicitly elevate equity to be equal to the other pillars in 2020.
How do you accomplish the best outcomes from providers’ care? And how do you drive the correct incentives that will have the most effect on provider behavior? First, I’d say that it’s not only about the incen- tives; they matter—they’re necessary, but not sufficient, to achieve the kinds of care we want to achieve. And the measures in the pay-for-equity are called the alternative quality contract. And the contract always gets the most attention, but I think that that does a bit of disservice to the totality of the elements. And one key element involves the timely sharing of data with providers. And we added an equity element to the data we’re sharing with providers and also collecting from them. For many years, our providers have been used to getting quality reports from us; but in the fall of 2021, they for the first time got a report on how they did in terms of equity outcomes—confidentially to each provider. Let’s say they have an equity rating that finds the provider organization is not doing as well—the equity report goes to the health system level—and they can work to improve. And it’s especially important for the purposes of looking at inequities in care.
Is there actionable information in those reports? Yes, that’s the second component; it’s not in the report itself, but we provide technical support to each of the provider organi- zations. We provider people who act as trainers and consultants to them. We’ve been doing this ever since the inception of the alternative quality contracts back in
2009—so, well over a decade. And what we didn’t have a ton of experience in, in-house, was how to improve on equity. So we partnered and contracted with the Institute for Healthcare Improvement (IHI) in 2021, because they had had five years’ experience in coaching organizations on equity. And they helped us convene an equity action community—it allows pro- viders to share where they are, and receive help from experts. And the IHI did a ton of training of our staff. And all of the alterna- tive quality contract groups participate in it, along with our staff and IHI staff. And there are all sorts of technical supports around patient race and ethnicity. And how to begin to target individual equity measures for improvement, to produce verifiable closure of equity gaps.
How has it been going? It’s been going well. The providers are all already participating.
Are providers moving forward as you had hoped? Yes, in general, but I want to be a little bit humble about this. If I have a particular idea about what a health system should be work- ing on, and they have a different idea, they might be right. We’re new at this, and so are they; everyone is. But generally, yes—it was not hard at all to get provider systems inter- ested and engaged in participating in this product. And they’ve been very interested in the equity element. One thing that helps is that we gave a $25 million grant to the IHI to work with the provider organizations. And most of the money will already be out the door by the end of this year. And it would be difficult for the provider organizations to make the kinds of changes we’re looking for, without adequate resources.
Are you at all concerned that the financial fragility of hospitals might impede the advance of value-based contracting going forward? The financial fragility of hospitals is always of concern. I don’t think that that is neces- sarily linked to value-based contracting, categorically; everything’s in the details.
You have the advantage that you’re not starting from zero, then, obviously? Having had an alternative quality con- tract—ACQ—in place for over ten years, the providers are familiar with it. But yes, building it all from scratch would have bene very difficult.
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How would characterize the data and analytics element of this? When you move into measuring inequi- ties and constructing incentives based on them, the data challenges are considerable. We’ve spent a few years working through those challenges, and we don’t have it per- fect by any means, but we’re as advanced as anyone. We’ve collected a ton of race and ethnicity data, voluntarily, from patients, and we’ve done a lot of analysis.
What are you seeing overall? At a very high level, every health plan can do what we’ve done; it’s a matter of will more than anything else; and you can start now. There are no justifiable excuses for failing to collect self-reported race and ethnicity data from your mem- bers, or for using data to approach and address inequities. That can start tomor- row at every health plan in the country; it’s all possible.
What do the next few years look like on this journey forward with your providers? We’d like to get the remainder of the organizations eligible for pay for equity into pay for equity as soon as possible. Everybody’s already interested in it; the question from the CFO perspective, esp. given the financial pressures you’ve just outlined, is, are they comfortable mak- ing the substantial investments needed. And that’s our goal. We can invest in multilingual capabilities,
in working
with disadvantaged communities, etc. So expanding that model is the key thing. And the proof will be in the pudding. We hope that all of it will work; Hector Rodriguez, from UC Berkeley, funded by the Commonwealth Fund, and he and his team are doing ongoing qualitative analysis and eventually will do a quan- titative evaluation of our work. His team is called CHOIR. Press release.
How optimistic do you feel about the advance of value-based contracting in the overall U.S. healthcare system? I don’t have enough sense of other mar- kets, but my hope is that what we end up more frequently is good value-based contracting; I’d like to see effective value- based contracting be the norm. But doing VBC for VBC’s sake, is not the goal. It’s equitable, high-quality care with a great consumer experience. If we don’t get those four things out of it, there’s no point. HI
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