By Robin Mullet
Fostering a culture of equity across the entire Health and Human Services System is not just a lofty strategic goal for Fairfax County, Virginia. It is also something the Community Health Care Network (CHCN) has been actively working to achieve for many years. In the 1980s, the Fairfax County Board of Supervisors became concerned about the difficulties encountered by the County’s low-income and uninsured residents in obtaining health care, and financed a study of the issue. Documenting a significant need, the board then created the CHCN. The CHCN was developed through a strong collaboration between the County, the community, and private health care providers. Two clinics opened in May and June 1990, and a third opened in February 1996.
The three clinics treat about 15,000 uninsured patients per year, regardless of patients’ ability to pay. Roughly 80 percent speak Spanish and the remaining 20 percent are from a mix of subpopulations. The program is administered by the Fairfax County Health Department. In 2014, when the Robert Wood Johnson Foundation-funded Finding Answers program announced a grant initiative aimed at reducing disparities through payment reform, George Mason University approached the Health Department about participating in a pilot study. The study was a good fit for CHCN because its clinical provider, Molina, already had a performance-based payment incentive program in place.
The research team had to first determine where there were gaps in care and in health outcomes between patient groups, then tweak the existing performance incentive structure to address the disparities that were uncovered.
After collecting and analyzing electronic health records data stratified by ethnic groups in year one, the research team determined that Hispanic patients were more likely to receive “high performance” care for cervical cancer screening, diabetes control, and hypertension control than non-Hispanic patients. When the idea of disparities was first presented to staff, they acknowledged the concept but reacted strongly, saying, ‘”we treat everyone the same.” But treating everyone the same doesn’t necessarily result in the same outcomes. The data were then presented to staff who expressed surprise. Not wanting to dwell on their surprise, they immediately began to discuss the data, suggest reasons for the findings, and seek to problem-solve in order to improve outcomes.
A root-cause analysis in year two brought to light some differences that could help explain the disparities, like the difficulty getting translators for non-Hispanic populations, or the fact that more patients in certain Asian-American sub-populations are more likely to share a phone, which means they don’t always get messages from the clinic.
Working with the research team, the County and Molina agreed to tweak the payment incentives that all members of the care team earn for meeting quality care and productivity target measures (activities like getting a patient screened for cervical cancer or counseling a patient on smoking cessation).
The care teams include physicians, nurse practitioners, medical assistants, and other within-clinic specialists who treat patients. On the other hand, County staff who assist the care teams—such as referral specialists who make sure patients see in-house specialists as soon as possible; enrollment staff members who process applications for Medicaid or other medical resources; and public health nurse liaisons who link patients to maternity, speech and hearing, vision clinic or other Health Department services—are not eligible for the performance-based incentives. As public employees, these payment incentives are not allowed. Although not eligible for a payment incentive, the County staff continued to work with the clinic staff as part of the bigger team. At no time did we witness less engagement by the County staff due to the incentive structure: staff remained highly engaged and committed to the project. As one referral specialist reported, “It wouldn’t make a difference if I was incentivized or not…serving the patient to the best of my ability is what I was hired to do.”
Patients were incentivized with free co-pay vouchers for engaging in certain health behaviors, like getting a flu vaccine or completing diabetic nutrition counseling.
Linking incentives to outcomes helped promote a team approach to patient care and also inspired some healthy competition between the three clinic sites. After only a year of implementation, the researchers started to see significant differences in clinical quality metrics across the three locations.
In July 2016, a new vendor, Inova Healthcare, was contracted by Fairfax County to operate and manage the day-to-day operations of the CHCN sites. This change brought significant turnover in staff. As such, momentum was lost and it was almost like ‘starting all over’ with the grant. However, change is real life. Implementing the team approach and continuing the performance incentive structure moved forward…for the second time!
Staff continue to be committed to reducing disparities and improving the health of our patients. We hope that the findings from the grant will add to the Health Department’s efforts at improving quality services, reducing disparities and improving community health outcomes.
Robin Mullet is Acting Program Director at Fairfax County Community Health Care Network.