National Quality Forum Presents "Roadmap" for Reducing Disparities

Triumphs in science and improvements in healthcare delivery do not fall equally to all groups, and giving health systems a tool to measure differences in how ethnic and socioeconomic groups experience healthcare can help narrow these gaps.

The National Quality Forum has issued a report, “A Roadmap for Promoting Health Equity and Eliminating Disparities: the Four I’s for Health Equity,” which calls for providers and payers to take steps to eliminate disparities. The report is one of the fruits of a project funded by HHS to find policies to bring the same level of healthcare to all, no matter where patients start.

“NQF is deeply committed to achieving health equity for all Americans,” said Shantanu Agrawal, MD, MPhil, NQF’s president and CEO. “The health equity roadmap gives the nation a blueprint to eliminate healthcare disparities."

The report discusses 4 specific actions for health systems:

• Identify and prioritize health disparities; this will include stratifying which should be addressed in the short term and which are long-term pursuits.
• Implement evidence-based interventions that can put at-risk patients in touch with services or culturally appropriate resources to reduce disparities.
• Invest in the use of health equity performance measures.
• Incentivize reducing disparities by building measures into new payment models.

Agrawal will be the plenary speaker October 26 at the fall meeting of the ACO and Emerging Healthcare Delivery Coalition^®, an initiative of The American Journal of Managed Care^®. (To register for the meeting, to be held in Nashville, Tennessee, click here.)

Marshall Chin, MD, a healthcare ethics professor at the University of Chicago who served as co-chair of the NQF’s Disparities Standing Committee, said the roadmap offers advice at the health system level “to ensure that all Americans get a fair shot at good health and high-quality healthcare.”

The report finds that creating good payment models is key—health system need incentives to close the outcomes gaps between socioeconomic groups. Despite support for moving toward outcomes-based reimbursement in Medicare, there has been outcry that payment frameworks must not punish hospitals and providers that care for the nation’s poor. The report discusses this in its executive summary:

“Because many quality measures used in alternative payment models, particularly outcome measures, show disparities that may or may not reflect disparities in underlying processes of care, it is essential that these models are not implemented in such a way that safety net providers are unfairly penalized,” it states.

The report says health systems should be paid more to care for more complex patients; for example, reimbursement should recognize it takes longer to discharge a homeless person because the hospital must find a placement. Bundled payments for a person with no stable housing may have to account for a longer stay in postacute care, the report says.

This report follows several effects to address healthcare equity in recent decades. Notably, there was the 2001 landmark document, “Crossing the Quality Chasm.” Published by the National Academy of Medicine, formerly the Institute of Medicine, that report established the principle that equity should not vary because of social characteristics, such as gender, ethnicity, geographic location, and socioeconomic status.

For example, the NQF document features a table explaining how common measures for cardiovascular, diabetes, cancer, and mental health care, as well as low birth weight, are all affected by socioeconomic conditions. Identifying all measures affected by disparities is challenging because the area has not received enough study; most research, the report says, looks at overall improvement in populations “rather than improving outcomes relative to a socially privileged reference group (e.g., white vs. African American).”

Interventions that do exist typically seek to change patients, not health systems that serve them. In the future, changes must be aimed at re-engineering the systems themselves. “Existing interventions largely focus on patient education, lifestyle modification, and culturally tailored programs,” the report states. “Far fewer interventions address how to improve health systems for populations with social risk factors.”

The report features several specific recommendations:

1. Collect social risk factor data.

2. Use and prioritize stratified health equity outcome measures.

3. Prioritize measures in the domains of equitable access and equitable high-quality care for accountability purposes.

4. Invest in preventive and primary care for patients with social risk factors.

5. Redesign payment models to support health equity.

6. Link health equity measures to accreditation programs.

7. Support outpatient and inpatient services with additional payment for patients with social risk factors.

8. Ensure organizations disproportionately serving individuals with social risk can compete in value-based purchasing programs.

9. Fund care delivery and payment reform demonstration projects to reduce disparities.

10. Assess economic impact of disparities from multiple perspectives.