“Our strongest lever to influence change in health care is the way we pay for care,” said Andrew Dreyfus, CEO of Blue Cross Blue Shield.
Dreyfus said the insurer was moved to act after witnessing the uneven toll that COVID-19 took on communities of color. Blue Cross Blue Shield used a similar lever in 2009, rewarding health systems for keeping patients healthy instead of paying them for each interaction they had with a patient.
That program required Blue Cross Blue Shield to gather data and build tools that would allow it to track progress, something it has done again with the new reimbursement model.
As part of an effort to showcase the disparities and build consensus for change with its providers, Blue Cross Blue Shield last year published a report looking at approximately 1.3 million of its own members and found vast disparities along racial lines when it came to colorectal cancer screenings, maternal morbidity, rates of adolescent well visits, and rates of recommended antidepressant medication management.
The insurer also provided data to each of the provider groups it worked with, illuminating the disparities that existed within their own hospitals and physician practices and letting them know how they performed relative to their peers.
Months later, the company gave $25 million in grants to physician practices and hospitals, distributed by the Institute for Healthcare Improvement after a review of project proposals, to support them in efforts to address disparities.
Then, as several contracts came up for renewal, Blue Cross Blue Shield began suggesting that an equity component play a big part in reimbursements. Many of the providers were already doing work to track disparities and narrow them, so tying financial incentives to health equity outcomes made sense.
To monitor the work, the Center for Healthcare Organization and Innovation Research at the University of California Berkeley School of Public Health will conduct an evaluation and track the effects of the initiative, funded by a grant from the Commonwealth Fund.
Dreyfus said health systems will have to show an improvement against their own past performance, rather than improving more than other systems, a design he hopes encourages systems to share their successes with one another.
Health systems said the new initiative would incentivize them to expand the work they have already been doing.
Juan Fernando Lopera, chief diversity, equity, and inclusion officer at Beth Israel Lahey Health, said an internal analysis done before the grant found that Black and Hispanic patients at BILH had a two times greater risk of having significantly high blood sugar compared with white patients.
With an initial $1.7 million grant from Blue Cross Blue Shield this fall, the health center began making changes at several primary care practices in its system, such as hiring navigators to help patients with chronic conditions such as diabetes and hypertension find resources to help with food or housing insecurity. BILH also developed new patient outreach tools, including texting platforms in multiple languages.
“The contract will put more incentives in place to continue to improve in closing those disparities,” Lopera said. “They are deeply rooted and difficult to move, which we’re learning. It will create that continued focus that is needed to [bring in] more resources.”
As part of its contract with Blue Cross Blue Shield, Steward is hoping to close disparities in several types of cancer screenings, including breast, colon, and cervical cancer. It also plans to work to eliminate gaps in the care and treatment of diabetes and high blood pressure.
Dr. Joseph Weinstein, chief physician executive at Steward Health Care Network, said the barriers to something as simple as a mammogram may feel insurmountable to someone who has no access to transportation, doesn’t speak English, and can’t take a day off work. Despite the system trying to address those gaps through interpreter services and instructions in other languages, Steward has struggled to solve the larger access problems.
“Instead of a one-off, this is a partnership,” Weinstein said. “It’s not Steward working on it by itself . . . entities are coming together, bringing resources to bear, to say, ‘No longer should poverty be a reason your health outcomes aren’t what they should be.’ ”
Dr. Thea James, vice president of mission and associate chief medical officer at BMC, said her system set out a year ago to understand not only what disparities existed in the care they provided, but their root cause, undertaking patient and physician interviews to add greater context to their findings.
The contract with Blue Cross Blue Shield will enable BMC to scale that work and hold people across the system accountable, she said. Specific to its contract, BMC will focus on disparities in colorectal cancer screenings and controlling high blood pressure.
“I don’t know of a time when I’ve been more excited,” James said. “It’s more than hope. A lot of times, with hope, you see people are on the right track. But when you are held accountable, you have to get it right. There’s a lot at risk.”
Mass General Brigham also amended its existing contract to include equity initiatives. The program will expand the work it is doing through its United Against Racism initiative, which addresses disparities in chronic disease, cancer prevention, and more.
“We are delighted that Blue Cross Blue Shield has committed to making an investment in providing equity through their payer models, as it takes real money to address this very important issue,” said Dr. Tom Sequist, chief medical officer of Mass General Brigham, in a statement.
The program launch comes weeks before Dreyfus is set to step down as CEO at the end of December, though he said that incoming CEO Sarah Iselin is equally committed to this approach. Additionally, Dreyfus hopes the independent evaluation will show results and build future momentum.
“I’m aware that the issues are big. They’ve been around for a century. They’re not going to get solved overnight. We’re going to have to expand this work,” Dreyfus said. “We expect other payers to join us in this work over time. So it’s an important start.”