By Marshall H. Chin, MD, MPH

Today the National Quality Forum (NQF) published an important report entitled A Roadmap for Promoting Health Equity and Eliminating Disparities: The Four I’s for Health Equity. NQF is a not-for-profit, nonpartisan organization comprised of diverse public and private stakeholders who use performance measurement to drive quality improvement.

The report lays out 4 “I’s” for Health Equity, actions that health care stakeholders can use to reduce disparities: 1. Identify priority disparity areas; 2. Implement evidence-based interventions to reduce disparities; 3. Invest in health equity performance measures; and 4. Incentivize the reduction of health disparities and achievement of health equity. 

The report also provides 10 recommendations to guide systematic implementation of the roadmap for disparities reduction:

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 payments 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.

The three overarching themes of the 10 recommendations are: prioritizing performance measures in the domains of Equitable Access and Equitable High-Quality Care for accountability purposes; redesigning payment models to support health equity; and considering additional payment for organizational factors that fall outside of the control of safety-net organizations and other providers serving individuals with social risk factors. Moreover, the report states that performance measurement and payment policies need to be explicitly designed with the goal of reducing disparities if health equity is to be achieved.

The report also recognizes that a sensible approach to achieving health equity utilizes multiple policy levers rather than focusing on an isolated one such as adjusting clinical performance scores for patient’s social risk factors. Recent reports by the National Academy of Medicine (NAM) and Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) also recommend rewarding better outcomes for patients with social risk factors. This shared recommendation by NQF, NAM, ASPE, and the RWJF Finding Answers program shows the consensus for incentivizing and supporting equity in payment programs.

As Co-Chair of the NQF Disparities Standing Committee, I’d like to highlight how a diverse committee that included representatives of health plans, labor unions, consumer advocacy groups, disease-focused organizations, professional associations, and researchers led to a better report. With a shared commitment to advancing health equity, the committee members’ diverse backgrounds and responsibilities led to a more robust set of recommendations.  

It has truly been an honor to work with such a dedicated, mission-driven committee and staff from NQF. I believe the resulting report has the potential to truly advance our thinking and policies for achieving health equity. Now we must implement the recommendations. For our part, Finding Answers is committed to helping payers and providers work through this process, including our current grantees, who are exploring just these types of payment and delivery reform projects to promote equity.

Graphic courtesy of National Quality Forum, “A Roadmap for Promoting Health Equity and Eliminating Disparities: The Four I’s for Health Equity” (September 2017)