Health Plan Design: Employers as the Architects of Health Equity

In recent years, there has been a growing acknowledgment of the pivotal role employers play in advancing health equity through the design of equitable health plans. The recognition that health disparities are not solely confined to the domain of health care providers or governmental agencies has led to a paradigm shift. Employers, who are the gatekeepers of employee well-being, have emerged as influential contributors to the pursuit of health equity.

Bruce Sherman, MD, medical director of North Carolina Business Coalition on Health, and adjunct professor at the Department of Public Health Education, University of North Carolina-Greensboro, emphasized the importance of equitable benefits for employees in an interview with The American Journal of Managed Care^® (AJMC^®).¹ Equitable benefits would encompass access to affordable health care, stable employment with a living wage, and opportunities for professional advancement, he said. The focus on health benefits underscores the need for employees to access and afford the care they require, with attention to the relevance of these benefits to individual employees.

Bruce Sherman, MD

“This one-size-fits-all approach to benefit design is great for individuals that are at a living wage, or well above a living wage,” Sherman explained. “But for those who are marginal, affordability is a challenge and people tend to forego care or delay care in that setting.”

Barriers to Equitable Access: Expense and Benefit Education

Health benefits are not only expensive, they’re complicated, according to Sherman, a longtime member of the AJMC editorial board. Education, especially for those in lower wage categories or minority subpopulations, is crucial to ensure that employees can use their health benefits appropriately.²

“That's an area where I think we have a great deal of opportunity to improve the health benefits that employers provide,” he said. “It could be a simple thing to lower health care costs to improve access, but that by itself is insufficient to affect meaningful change.”¹

The complexity of health benefits is not only an obstacle for employees but for employers too. Many employers understand the importance of equitable health plan design, but they lack the necessary knowledge to achieve it, Vikki Walton, MBA, health equity leader at Mercer, explained in an interview with AJMC.³ Mercer is a health equity consulting group that aims to address gaps in employer health benefit design.

Vikki Walton, MBA

“We go in and we first have the conversation about education. So, we have to educate them. Again, a lot of times employers recognize that with health equity or social determinants of health, they might know a little bit about it, but not so much,” she said. “So, we go in and we have to educate staff around exactly what it means. And then we go in and we start to assess their actual benefits. We go in and do a deep dive into what they're offering and then tie it to different groups of cohorts.”

Mercer’s approach also involves data harvesting, or a deliberate and systematic effort to collect and analyze information related to employee populations. The goal, Walton said, is to prompt employers to reflect on the composition of their data, emphasizing its role in guiding interventions for diverse populations.

Because of the multifaceted nature of health disparities, the social vulnerability index aids in evaluating the social determinants of health and identifying populations facing challenges in accessing care. This analytical foundation allows for targeted interventions that can address specific needs within the workforce, contributing to a more equitable and responsive health benefits structure.

“So, if we are looking at the LGBTQ+ community, what are they doing around gender-affirming care? If we're looking at women, reproductive health, what are we doing? What are we offering? How can we support that? What does travel and lodging look like for those who want to have care at centers of excellence?” she continued. "We go in and we do a deep dive, which will take some time, to assess what they currently offer.”

Centering the Provider-Patient Relationship

Sherman addressed the critical role of relationship-centered care in overcoming medical mistrust, implicit bias, and systemic factors.¹ He pointed out that meaningful and trusted relationships between individuals and their clinicians are essential for improving health outcomes. This is particularly crucial for minority subpopulations and lower-income groups, where systemic factors negatively impact health. The need for a more focused effort in building cultural sensitivity among clinicians to bridge the gap in health outcomes is essential.

“We are only going to see improvements in health outcomes and a narrowing of the health inequity gap if individuals can have a meaningful and trusted relationship with their clinician because that's what will help to overcome medical mistrust and implicit bias,” he said. “And when that takes place, that's why we will see outcomes improve.”

While there are training programs to improve cultural sensitivity among clinicians and tools to overcome language barriers, Sherman believes health plans should take more initiative to facilitate the option for racial concordance so employees can be aware of the race or ethnicity of their potential health care providers.

“We know from the literature that racial concordance makes a big difference,” he said. “If you are the same race or ethnicity as your clinician, that will likely improve your outcomes. But there isn't an even distribution of clinicians to match the racial, ethnic profile of the population of the United States.”

Advocating for Systematic Measurement

Both Sherman and Walton acknowledged the necessity of a systematic measurement approach to address and improve health equity outcomes.^1,3 Sherman argued that reducing disparities in health outcomes, particularly among individuals of different races, ethnicities, or socioeconomic statuses, requires a standardized method for assessing and managing health inequities.¹

The call for a measurement approach is presented as essential for comprehensively understanding where gaps and variations exist in health care outcomes. He advocated for a reporting system that extends from health systems and plans to employers, with the ultimate goal of making this data accessible to employees. By fostering transparency and providing standardized information, the speaker contends that such reporting mechanisms will empower stakeholders at all levels to actively contribute to and comprehend efforts aimed at achieving improved clinical outcomes and reducing health disparities.

“We know employers make up about 50% if not more coverage for employees within the US," Walton said. "And so it's very, very important that they play a role in this entire ecosystem of health equity."³

Sherman's insights, coupled with the innovative approaches outlined by Walton, underscore the pressing need for a paradigmatic change in the approach to employee well-being. The multifaceted challenges of health benefits, from affordability to complexity, demand more than just cost-cutting measures; they necessitate a holistic transformation.

References

1. Grossi G. Dr Bruce Sherman explores the role of equitable health benefit design in the US. AJMC. December 16, 2023. Accessed December 22, 2023. https://www.ajmc.com/view/dr-bruce-sherman-explores-the-role-of-equitable-health-benefit-design-in-the-us

2. Jenkins KR, Stiehl E, Sherman BW, Bales SL. Supporting employee health at work: how perceptions differ across wage category. Am J Health Promot. 2022;36(1):169-174. doi:10.1177/08901171211024416

3. Grossi G. Vikki Walton, MBA: bridging health equity gaps through DE&I. AJMC. September 26, 2023. Accessed December 22, 2023. https://ajmc.com/view/vikki-walton-bridging-health-equity-gaps-dei