Abstract
Earlier this month, stakeholders across the healthcare industry came together at America’s Health Insurance Plans (AHIP) conference to discuss the need to make healthcare more accessible, affordable, and transparent.
Of the various sessions, many focused on – and the majority at least mentioned – health equity and the obstacles and approaches to fostering it. We joined sessions with experts in the field such as Dr. Anthony Fauci, and leaders from BCBS of Massachusetts, Sharp Health Plan, UCare, CareOregon, Ovia Health, and others as they shared their thoughts on the topic and what they are tactically doing to move towards it. For each, a foundational element was building trust within communities by empowering frontline workers. They discussed how elevating Community Based Organizations (CBOs) and restructuring payment models has enabled them to move towards a peer-based health system and away from the classic, paternalistic system that is not set up to reduce inequity.
At Siftwell, we share the view that the initial groundwork to sustainably improve health equity is by health plans’ working with members in a more empathetic and context-rich way, via the communities that are familiar and intertwined with them. So how is that done?
The Foundation of Health Equity: Building Trust and Engagement in Communities
“Progress moves at the speed of trust”
This profound quote sheds light on the fact that the efforts to create meaningful change must take place at the community level first—where its members can be engaged directly by those they already know, relate to, and, well, trust. The “faces” of healthcare within communities are often community health workers, such as social workers, doulas, and other professionals. They know communities’ social and health-related needs best, and the communities know them, but they struggle because the services they provide are not always classic medical services and reimbursement is not straightforward. Most of these workers get by on humbling salaries and lack the means to be compensated for the holistic care they provide to people. Though lip service is paid to their importance, they are treated as a kind of “second tier” care delivery organization that lacks the earning and growth power of health systems or other medical provider organizations.
Innovative payers who are committed to build health equity in their communities have begun the journey by changing this dynamic. They are focusing resources on CBOs and on compensating them appropriately for the role they play across the broad-based health of a family. This can be a heavy upfront investment, as shown by the few examples below. But beginning to pay CBOs similarly to how health systems are paid elevates them as true community care partners. They can be compensated for the holistic care they provide, be able to recruit more high-quality community members to join them via more competitive salaries and benefits, and invest in workflow technologies that allow them to more effectively serve more community members. Indeed, these payers have invested in health equity by first giving their care delivery communities more equitable access to resources to serve the population.
This is a peer-based healthcare system, where each organization plays a complementary role in supporting the population and is properly incentivized to do so. Once a peer-based healthcare system is established in a community, more of the community will naturally be interacting with and trusting that healthcare system. As CBOs become more established, members have more healthcare workers they trust and are more likely to be engaged in preventative care and in timely acute care.
CBOs are incredibly familiar with their communities, and their involvement also lets the care delivery system learn from them and evolve. An example of this exists around systemic norms that deter patients from preventative care. These norms can seem basic and are often unnoticed. For example, words like ‘care management’ and ‘case management,’ can hinder patients in minority communities from pursuing care, as these words are heavily stigmatized and are associated with an imbalance of authority. Spreading the understanding of these fine yet critical details can help identify and reframe facets of healthcare that are common practice but are ultimately preventing patients from seeking preventative care and trusting the care delivery system, further widening the gap of inequity.
A Specific Example: Maternal Health
Let’s see how the above plays out by looking at a specific example. Health inequity starkly exists in maternal health for minorities. Following the recent death of former Olympian Tori Bowie, the lack of progress in this space for minority mothers is plainly evident. It is estimated that 80% of pregnancy related deaths are avoidable and of these preventable deaths, Indigenous people are almost double the risk. These disparities are most dramatically highlighted within premature birth (delivery before 37 weeks of gestation). Premature births saw a 40% surge in 2021 and unfortunately, there is no decline in sight. Of those mothers that experience premature birth, Black women are 50% more likely than other mothers to deliver their babies early.
To establish trust and solve problems within the community, people who are most representative of its members must be empowered and engaged. As discussed above, doulas are one type of community health worker that are not clinicians but can have a great impact on patient outcomes. Doulas are often working within their own community and therefore ‘look the same’ as the patients they serve, leading to higher empathy and trust. This is what makes them incredibly effective and adds immense value by improving care as well as mitigating racial bias in maternal care. This is a real example of how outcomes are enhanced by having a community health worker, who may or may not be a part of a CBO, involved in patient care.
Unfortunately, but unsurprisingly, there is a major shortage of these critical workers, as they are underpaid and often switch careers after 3-5 years due to burnout. Additionally, it is exceedingly difficult for doulas to bill through Medicaid, further limiting their earning potential.
Health Plans Leading the Way
The good news is that select payers are starting to invest this area at the grassroots level. Here is how real payers are taking steps to empower doulas and other community health workers to improve outcomes for their members:
Sharp Health Plan
With a 5-star rating for maternal health, Sharp Health Plan is a strong model for improving outcomes in maternal health. Sharp implements both modern predictive analytics as well as doulas on the ground in the community to combat disparities in maternal health. Their predictive modeling platform reviews medical records to help identify high risk patients from the time of pregnancy. Domains like language barriers, SDOH, and other parameters help identify at-risk mothers to get them engaged in care early on while ensuring they understand and have access to their benefits. This allows doulas to focus on high-risk members and generate additional margin for Sharp to pay them adequately for their services.
Blue Cross Blue Shield (BCBS) of Massachusetts
As the first payer to publish an equity report Blue Cross Blue Shield (BCBS) of Massachusetts is leading the charge for health equity. BCBS of Massachusetts is taking strides to create equity at both the systemic and community level as they have structured drivers into their value-based performance contracts. Providers contracted with the plan must commit to improving some aspects of maternal morbidity. This incentivizes health systems to work together with and often employ doulas directly. The plan also leverages virtual networks to offer doula services locally in person as well as virtually and prioritizes member education to ensure patients are aware of all perinatal and postpartum benefits available to them.
CareOregon
In an effort to shift the dynamic between plans and community organizations, CareOregon has implemented a program dedicated to working directly with CBOs to develop payment models that compensate according to the care delivered and added value. The program, which is in its second year, teaches CBOs the skills to negotiate contracts, rates, and help them effectively deliver care within the community. The goal of the program is to ultimately support the efforts of the CBOs, but most importantly to elevate them as peers to health plans.
The Role of Predictive Analytics
Predictive analytics, such as that being implemented by Sharp and the analytics solutions offered by Siftwell, play a vital role in making healthcare more accessible, affordable, and transparent. By providing analytic tools and predictive modeling, Siftwell enables community health workers, call centers, and care managers, to improve decision-making and empowers them to take effective action. With Siftwell’s solutions, organizations can leverage the power of artificial intelligence to enhance their understanding of data, make informed decisions, and deliver care in a more efficient and empathetic manner.
AHIP provided valuable insights into the need to address health equity through community empowerment and workforce development. The conference emphasized the significance of building trust, engaging communities, and recognizing the expertise of CBOs to help make healthcare more accessible, affordable, and transparent.
Siftwell is committed to helping health plans work with members in a more empathetic and context-rich way. By leveraging Siftwell’s solutions, organizations can enable community health workers to excel in their roles to ultimately make meaningful progress in creating a healthcare system that is equitable for all.
