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Will Hospitals Serving Racial and Ethnic Minorities Lose Out in a Value-Based Payment World?

HMA Principal Madeleine Shea, with her partners from the National Committee for Quality Assurance and American Hospital Association, recently authored the Health Equity article, Explaining the Relationship between Minority Group Status and Health Disparities. While federal policy has moved in the direction of adjusting for poverty and disability as proxies for social risks, this article keeps the focus on race and ethnicity as a major explanation for health disparities in the United States.

There is a well-documented relationship between race and health disparities including the 1985 response by the Health and Human Services Secretary’s Task Force on Black and Minority Health to a national paradox.  The country was celebrating steady improvement in overall life expectancy and health but experiencing huge disparities in most health indicators among Blacks, Native Americans, Hispanics, Asians and Pacific Islanders.  Today, as we move away from fee-for-service to value-based- payment, particularly in Medicare and Medicaid, federal policies have generated national attention about the impact that social risk factors have on health outcomes.

The goal is not a payment system that unfairly underpays for providing quality care for people who need more, nor is it a payment system that rewards poor quality care by paying extra when the quality of service is not good. Instead, federal agencies want to understand the relationship between race, ethnicity, income, education and other factors of socioeconomic disadvantage. This broader investigation of social risk factors has, in fact, reduced the focus on race and ethnicity as risk factor for disparities in health and healthcare. However, understanding the independent contribution of minority group status is critical to this discussion.

In our Health Equity article, my co-authors and I bring four concepts into the mainstream discussion about the contribution of minority group status and its association with health disparities. These four factors are: minority stress, resilience, life course and epigenetics. Each factor is important.

The minority stress model is a framework for conceptualizing how experiences unique to minority groups—prejudice and discrimination, in particular—confer chronic psychological stress and heightened physiological responses that impact mental and physical health over time.

Resilience generally refers to positive adaption in the face of negative life experiences or adversity—including threats and trauma like adverse childhood events.

The life course perspective may be the most important factor. It emphasizes the importance of the accumulation of biological, physical and social factors over a person’s life span. Exposure to these factors and others may interact with and modify epigenetic regulation, biological processes that impact how genes are expressed. This may increase the risk of disease and negative health outcomes, particularly among groups that may be at disproportionate risk because of social circumstances and environmental exposure over the life course.

Read the full article to learn more about why not considering race and ethnicity in value-based payment may be missing the mark. Are we unfairly disadvantaging providers that serve a high-proportion of minorities? https://www.liebertpub.com/doi/pdf/10.1089/heq.2018.0035

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