Host Jeff Goldman, Director of the LAN through the MITRE-operated Health FFRDC, interviews Dr. Andrea Gelzer, Senior Vice President and Chief Medical Officer for AmeriHealth Caritas, and Karen Dale, Market President of AmeriHealth Caritas District of Columbia. In this episode, they share how their organization is responding to issues of equity and access while promoting value-based payment initiatives to improve outcomes.

Karen Dale (12:15): Yes.

Andrea Gelzer (22:39): Sure. I mean, I, and I would say that a lot, there are health equity initiatives now coming from every state Medicaid agency. But they're coming as expectations, I would say, for the plans. So, they're coming not as a request, but it's like everyone, everyone is, is trying to address health equity, trying to address social determinants, trying to address disparities. And there is certainly a renewed interest and renewed interest. Nope. I would say that many, you know, no one has the silver bullet, and I think that we are we're all working together and... But as I started, as I started my answer, it's really expectations that we're seeing, and I think that the state is looking for solutions. Every state is looking for solutions to this. So that's why it's so important that multi-stakeholders sit in the same room and try to work on these issues to impact outcomes.

Andrea Gelzer (27:56): Yeah, I think that whatever the model to promote health equity, they're always quality gates in a model. And I believe that what, whatever the alternative payment models, if it's a population-based model with quality gates, those quality gates have to include measures, measures of health equity. I think we're still nascent in which of those measures truly drive outcomes but including them is a very good first step because outcomes alone aren't the only measure. You have to take a really deep dive into the outcomes, and you also have to make sure that you look at the outcomes and stratify them by race, ethnicity, language, social determinants. So if providers may meet benchmarks, for example, for a certain population, but performance is still lagging as compared to the pa-, you know, so they meet the benchmarks for one certain populations, but their performance is lagging compared to the population at large, there's still an equity issue. So we're using this approach by taking existing, we're trying to take existing quality measures and really bifurcating the baseline data by race, ethnicity, and language, to look at opportunities for improvement. And I can l give you an example. Docs earn more if they improve access to care, care metrics for the African-American population if a disparity exists for that population. So really target, target the incentives to produce improved outcomes for the population where the performance measure is lacking.

Andrea Gelzer (31:09): I think we've talked about the barriers and I, you know, a lot of the barriers, the same old barriers we've talked about before that, that providers aren't ready, or as Karen says, Karen noted, they, you know, you're adding, you're adding on something for them to do that they don't particularly have time to do because of their workflow issues. I think it's still too early in the game. I think really we, we need to, we all need to get better at designing alternative payment models to really deliver the results and to work and respect the providers as well as our members to see that those programs are successful.

Andrea Gelzer (38:28): Oh, I think that's absolutely right, Karen. And we've been a supporter of Gravity since its inception looking at how we collect social determinant data. I think that that's a great example too, of a multistakeholder collaborative, where everyone's sitting at the table trying to reach consensus on how we collect these data.

Karen Dale (39:09): Sure. So as we think about equity, and it's certainly top of mind for me coming out of the pandemic, right? 60 days after the pandemic ends, it's very likely we'll have this tsunami in terms of evictions across the country. We know that housing is a stabilizing force for communities and people that we serve. And we know that in many of the communities that are going to be most affected, they won’t have representation. So, what happens next? This is the kind of thing that gives us an opportunity to utilize an equity lens. And they, what can we do? So what if you have an entity, like in the District, we have the Children's Law Center. We have DC Legal Aid. What if we were reimbursing them, right? And looking at outcomes in terms of how they might prevent evictions, right? And so we can come up with ways to address things that are challenges, health harming when not addressed, by looking back, by using alternative payment methods for even other types of organizations that I call health adjacent, because they're still important to what we're trying to accomplish around health and health outcomes. Similarly, you think about where we may need respite housing, right? For someone who is able to be discharged from the hospital, can go home with health support, however they're experiencing homelessness. So if we don't address that, then they are readmitted, we've got more cost in the system than needed. So what if we have a place where they can go, and that place has a value-based, you know, or alternative payment models. So we have one of those, which is awesome. And you know, we're looking at one with one of our organizations that supports moms, right? In terms of providing peer support, which is almost always in-person in some way, or, you know, over Zoom these days so that when they produce better health outcomes, you know, more babies that are full term, more moms that kept all of their appointments, all of those kinds of things become the measures of whether they’re meeting the quantitative and qualitative measures in an alternative payment model. So those are some things that are really exciting that we are starting to do, that, again, through a health equity lens show the promise of what we can achieve by thinking about things differently. Andrea Gelzer (41:52): And we've also had a very positive experience participating in the Advancing Health Equity, it's called Advancing Health Equity, Leading Care Payment, and Systems Transformation. It's a national program supported by RWJ, and it's a learning collaborative. And through it, we're working with, we're working with the state Medicaid agency in Delaware along with a provider partner to design a value-based model that supports delivery system transformation to reduce, eliminate disparities in healthcare and through this program, I think we're not only learning about ways to close the equity gap to meet the needs in Delaware, but we're also able to benefit from the best practice from other participating stakeholder teams nationwide.