Improving health equity in the US will require changing health care payment. But despite the success of value-based payments in resetting expectations away from volume-based reimbursement toward quality and cost efficiency, these arrangements, historically, have not been designed to combat longstanding health inequities.
In fact, there is growing recognition that even as value-based payment arrangements attempt to promote financial sustainability and better care, they can unintentionally entrench or exacerbate existing health inequities. One fundamental reason is that value-based models are founded on accountability for patient outcomes and cost, with participating clinicians and hospitals earning financial bonuses for hitting cost and quality targets. This design can deter hospitals and clinicians from caring for patients whose costs and quality of care appear difficult to manage, including those from marginalized communities.
While the policy and practices communities have mobilized to address these issues, activity does not necessarily equal progress. Simultaneous work from many different groups will be required to create momentum toward equity goals. But if uncoordinated, multiple efforts could also unintentionally generate an unproductive combination of activities. To advance equity through payment reforms, policy and practice leaders must implement strategies in a systematic, coordinated way. These strategies, and their underlying principles, should be consistent across patient populations and insurance types, even if some implementation details differ.