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Value-based payment (VBP) is a powerful and widespread health care transformation movement that has potential to improve health equity. The care delivery and payment flexibility possible under VBP (for example, to address social needs or hire community health workers), and the care coordination emphasized, are difficult at best or impossible at worst under fee-for-service reimbursement. Pairing that flexibility with VBP models’ financial incentives to improve care quality and value can make advancing equity a reality—if there are specific equity-focused design elements and incentives.
Accordingly, the Center for Medicare and Medicaid Innovation (the Innovation Center) redesigned its Global and Professional Direct Contracting Model earlier this year to be an equity-focused VBP model, ACO (ACO) REACH (Realizing Equity, Access, and Community Health). With the creation of ACO REACH, the federal government joined a handful of statesand commercial payers taking steps to directly include equity in VBP model design. Additionally, the Centers for Medicare and Medicaid Services (CMS) is seeking comments on potential proposals for rolling equity-focused VBP principles into a variety of Medicare programs, including the Medicare Shared Savings Program.
Without an explicit focus on equity in model design, however, VBP models could perpetuate health inequities by not including historically marginalized populations and their providers or by not encouraging providers to identify and address health disparities. In a recent two-part articlein Forefront, we discussed and categorized equity-focused design elements for use in VBP, highlighting examples, evidence, and early lessons from how CMS, states, and commercial payers do this in practice. For CMS to achieve the five priorities from its new Framework for Health Equity, though, equity-focused design is just the first part of the puzzle—it must be paired with equity-focused implementation.