GrantWatch By Rachel H. DeMeester, Lucy J. Xu, Robert S. Nocon, Scott C. Cook, Andrea M. Ducas, and Marshall H. Chin Solving Disparities Through Payment And Delivery System Reform: A Program To Achieve Health Equity ABSTRACT Payment systems generally do not directly encourage or support the reduction of health disparities. In 2013 the Finding Answers: Solving Disparities through Payment and Delivery System Reform program of the Robert Wood Johnson Foundation sought to understand how alternative payment models might intentionally incorporate a disparities-reduction component to promote health equity. A qualitative analysis of forty proposals to the program revealed that applicants generally did not link payment reform tightly to disparities reduction. Most proposed general pay-for-performance, global payment, or shared savings plans, combined with multicomponent system interventions. None of the applicants proposed making any financial payments contingent on having successfully reduced disparities. Most applicants did not address how they would optimize providers ’ intrinsic and extrinsic motivation to reduce disparities. A better understanding of how payment and care delivery models might be designed and implemented to reduce health disparities is essential. H ealth care disparities persist despite decades of research document- ing them, 1 determin- ing underlying root causes, 2 and testing solutions. 3 Differ- ences in the quality of care and health outcomes across dimensions such as pa- tients ’ race, ethnicity, and socioeconom- ic status cause much human suffering at great economic cost. 2 Multiple factors cause disparities in health outcomes, in- cluding unconscious bias and cultural insensitivity by clinicians and health care organizations; differential health care; and structural inequities in the so- cial, economic, and physical environ- ments in which people live. 2 The good news is that research and demonstration programs, such as the Finding Answers: Disparities Research for Change program of the Robert Wood Johnson Foundation (RWJF), 4,5 have elucidated what types of interventions can reduce disparities. 6 – 8 For example, multicomponent interventions that ad- dress the drivers of disparities are prom- ising, as are culturally tailored interven- tions; team-based care; community health workers and patient navigators; involving families and community part- ners in solutions; and interactive, skills- based training for patients. 7 Equitable care does not mean the same care for different patients, because it is neces- sary to individualize care to the particu- lar needs and challenges of specific patients to optimize their health out- comes. These interventions need to be embedded in a road map or systematic process in which health care organiza- tions and providers make achieving health equity a high priority and tailor solutions for their settings and popula- tions. 7 – 9 Too often, though, reducing health disparities has not been a priority for front-line health care organizations.
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