Alternative payment models may have the potential to address health equity by encouraging payment reforms that reduce race- or income-related disparities. But so far, there have been few payment reform proposals that get at the heart of the problem, according to researchers writing in the journal Health Affairs.
Disparities can be caused by a variety of factors: unconscious bias and cultural insensitivity, differential healthcare, and structural inequities are all potential suspects. Some programs, such as the Finding Answers: Disparities Research for Change program of the Robert Wood Johnson Foundation, have suggested a number of interventions, from team-based care and community health workers to community partnerships and skills-based training or patients.
The problem with the Finding Answers program, the authors said, is that so far it's found relatively few answers. The program asked providers and government entities with proposing solutions, but few have hit close to the mark; some have failed altogether to offer substantive financial incentives to reduce health inequity.
There may be a number of reasons for this. Healthcare systems and providers have been focused on more immediate concerns, such as implementing an electronic health record system, meeting meaningful use requirements and transitioning from fee-for-service reimbursement models to global and bundled payment. Health disparities are less immediately related to their bottom line.
Finding Answers sought to bring inequity to the fore through a grants program to study organizations attempting to use innovating payment and delivery system reform to address the issue. To date, results have been mixed.
Of the applicants to the program, 65 percent aimed to improve the care and outcomes of a racial or ethnic minority group without measuring disparities against a reference group, such as whites. About 45 percent of the applicants targeted multiple disparities, but 10 percent didn't target a specific disparity between groups.
Generally, the applications gave few details about payment changes. Several explored combinations of financial and nonfinancial incentives, such as feedback on performance or adding personnel such as a social worker or community-based dental hygienist.
None of the applicants met the full criteria, but a handful came close. The University of Washington partnered with Advantage Dental Services in Oregon to target disparities in oral health by improving access to dental care, focusing on changes to the care team and going outside of the traditional clinic to provide care.
George Mason University, Molina Healthcare and Fairfax County, Virginia, meanwhile, proposed a global budget to provide health services at three safety-net clinics for uninsured residents with household incomes less than 200 percent of the federal poverty level.
Yet even those measures don't go far enough, researchers said. More relevant proposals are needed, they said, because if health inequities are truly to be addressed, there need to be financial incentives built into any successful approach.