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By Andrew C. Anderson

As the health care system moves towards value-based payment, we need performance measures that can assess and monitor disparities in health and health care. The National Quality Forum’s Health Equity Roadmap provides a structure to reconsider longstanding disparities in the context of value-based payment and emerging care models. The Roadmap describes four actions for health care providers and payers to reduce disparities and promote health equity: identifying and prioritizing disparities reduction, implementing evidence-based interventions to reduce disparities, investing in the development of health equity measures, and incentivizing the promotion of health equity and the elimination of disparities.

Racial Disparities and Hypertension: The Roadmap Applied

An article published in the March 2018 “Advancing Health Equity” issue of Health Affairs applied the Roadmap to the issue of racial disparities in the prevalence and control of hypertension—a major source of premature death among African Americans. The American Heart Association estimates 40 percent of African American men and women have hypertension, high blood pressure, or both. African Americans are also more likely to develop hypertension earlier and it is often more severe. The National Center for Health Statistics reports that the gap in prevalence between African Americans and whites is nearly 10 percent.  

Many documented interventions have succeeded in both reducing disparities between African Americans and whites and improving outcomes within African American communities. The most common interventions are primarily non-pharmacologic and focus on changing behavior and providing additional levels of support through team-based care, lifestyle change programs, peer coaches and community health workers. Leading health systems in both the private and public sector have implemented these strategies with success. 

Models of Success

Kaiser Permanente’s Equitable Care Health Outcomes Program (ECHO) trained providers on tailored treatment intensification, strategies to improve medication adherence, and defined roles for hypertension management for each member of the care team. The ECHO program resulted in a 71 percent reduction in the gap between African American and white patients with hypertension. In addition, the Department of Veterans Affairs (VA) pay-for-performance program (a previous grantee of Finding Answers) that provides targeted incentives has demonstrated significantly improved blood pressure control among African American patients. However, despite the evidence of long-standing disparities and trailblazers demonstrating how they can be implemented, the uptake of evidence-based strategies to reduce hypertension among African Americans has been limited. 

Tying Payment to Performance: the Business Case

New payment policies tied to performance measurement have the potential to increase implementation of evidence-based strategies. Hospitals can use their community benefit dollars to conduct outreach involving prevention education, blood pressure screening, and hypertension reduction projects in the communities they serve. Health plans can encourage the implementation of interventions to reduce hypertension in office-based settings by increasing payments for primary and preventative care. There is a strong business case for addressing these disparities for organizations that assume financial risk in global, capitated, and bundled payment models, as reducing disparities has the potential to reduce costs.  

What is more, recent evidence suggests that emerging care models that have not prioritized health equity have the potential to exacerbate disparities. For example, the Medicare Shared Savings Program requires Accountable Care Organizations (ACOs) to report performance on a hypertension control measure (ACO#28) but does not require or incentivize reporting by the group most affected by hypertension—African Americans. In fact, between 2012 and 2014, ACOs that served a disproportionately high number of minority patients performed worse on 26 of the 33 ACO performance measures, resulting in penalties that may harm these organizations’ capacity to deliver care.  

A recent study demonstrated that providers who serve populations with more clinical and social complexity (e.g. African Americans with hypertension) are also at higher risk of receiving financial penalties in Medicare’s Physician Value-Based Payment Modifier Program. These initiatives, designed to improve care quality, have the potential to take resources away from providers serving patients with the greatest need.  

The Role of Advocacy

Performance measurement is only one, albeit important, tool for reducing disparities and achieving health equity. We also need sustained advocacy to ensure health equity becomes an integral component of quality improvement, which requires a commitment from leaders at all levels of the health care system and beyond. In addition, the health care system will need to collaborate with other sectors that influence the health of individuals (e.g. education, public health, transportation, and law enforcement). Without a targeted and consistent approach, disparities in hypertension and other conditions will persist. 

Andrew Anderson is a Senior Director at the National Quality Forum and a Robert Wood Johnson Foundation Health Policy Research Scholar.