Blue Cross Blue Shield of Massachusetts has announced four value-based agreements that link financial incentives to improvements in equity with the state’s largest health systems.
The plan says the move is the first in the state and among the first in the nation to create a financial payment model rewarding providers for eliminating racial and ethnic inequities in care. The four health systems are Steward Healthcare Network, Beth Israel Lahey Health, Mass General Brigham and Boston Accountable Care Organization (part of Boston Medical Center). Together, the systems care for more than half a million Blue Cross members.
“For more than a decade, we’ve collaborated with physicians and hospitals via our Alternative Quality Contract, which replaced the fee-for-service model and instead rewards clinicians’ efforts to improve the quality and value of the care they deliver,” Andrew Dreyfus, the insurer's CEO, said in a press release. “We’re now building on that model to help health systems in our value-based payment programs improve equity. As a health plan, this is the most important tool we have to work toward a health system that provides affordable, quality and equitable care to all our members.”
The new contracts will focus on measuring and rewarding equity improvements in a number of areas including colorectal cancer screenings, blood pressure control and diabetes care. Additional categories will be added as the payment model evolves. Metrics were borrowed from existing industry standards.
The process of creating the contracts took two years, according to Mark Friedberg, M.D., senior vice president of performance measurement and improvement at Blue Cross Blue Shield of Massachusetts. The plan sought input from a health equity council of advisers, dozens of its plan employees and, finally, from the health systems themselves, which were invited to brainstorming sessions on the design of the pay-for-equity program.
The quicker inequities are reduced, the greater the financial payout to the providers. They must do well on equity, quality and efficiency—the three components that now make up performance. “We don’t ever want to have savings occur at the expense of quality,” Friedberg told Fierce Healthcare.
Each provider has a slightly different set of measures depending on the scale and diversity of their patient populations and how large an inequity is at baseline, so an improvement can be detected. “We just want to be sure that we would be able to measure with a reasonable amount of precision true improvements in health equity over time,” Friedberg said.
There is a lot of money on the line—and that’s not because the plan believes that is what it would take to motivate providers to improve equity. “We didn’t need to excite them about this topic,” Friedberg said. “They arrived excited.” But Blue Cross worked to create a compelling business case for the finance executives of the health systems to ensure they would authorize the investments needed to improve equity.
The Institute for Healthcare Improvement has awarded approximately $20 million in Blue Cross-funded grants to 12 health systems across Massachusetts to fund projects to improve equity. The four in the latest agreements are among that dozen, and the plan hopes to onboard another cohort to the pay-for-equity program in 2024.
The funds go toward offsetting staffing costs, upgrading internal data and performance measurement capabilities and eliminating the root causes of the inequities, according to Friedberg.
The Center for Healthcare Organization and Innovation Research at the UC Berkeley School of Public Health is expected to conduct an independent external evaluation of the new pay-for-equity program. It may publish details on the success of the model’s deployment and provider feedback as soon as next year.
For other payers interested in similar efforts, Friedberg recommends starting by sharing data with providers on their performance in equity and providing the technical infrastructure needed to support improvements.
In Friedberg’s view, the last thing a payer should do is create a contract without offering help or data to the providers. Blue Cross gives providers regular reports on their quality measure performance and how they compare to others. Starting last year, the plan also began to stratify those data by race and ethnicity. The plan has also joined the Pursuing Equity Action Community led by the Institute for Healthcare Improvement for more technical assistance.
“Every group in Massachusetts has something they can work on,” Friedberg said. “Nobody has perfect equity, currently.”