Why Equal Care May Yield Lower Costs

Addressing the social determinants of health is an important piece of reducing health inequality, but the conversation must also be part of the emerging efforts between payers and providers to control costs.

"We must recognize that variations in the social determinants of health exist and represent major opportunities to improve health," says Dr. Derek Robinson, vice president of quality and accreditation for the Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas.

When Leanne Metcalfe went to the doctor for a lump in her breast, she was told not to worry because “black women have lumpy breasts.”

Fortunately, she knew from experience not to leave it at that.

A few years earlier, her friend and mentor, Shirley Miller, had been told the exact same thing after finding a lump. That dismissal cost her time, and cancer spread throughout her body. She died before her 40th birthday.

With all of this in mind, Metcalfe decided to return to her hometown in Jamaica to have her lump biopsied and receive care. Unlike her friend’s tumor, her cancer was caught and treated early.

“If I didn’t know what had happened to her, I don’t know what my decision would have been,” she says.

That experience at such a young age not only shaped her medical treatment, it also shaped her career. Today, Metcalfe holds a doctorate degree in biomedical engineering and directs a team of clinical data scientists for Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas.

In her role, she works to reduce health inequalities and improve quality of care for all populations. “Shirley is my inspiration,” Metcalfe says. “I’m going to fix this.”

Metcalfe recalls her friend saying, “If I have all this money, all this education, the best health care with the best doctors and this still happens to me, what’s happening to those women out there who don’t have this access?”

Defining equity

That question echoes ones asked every day by stakeholders throughout the health care system, from patients to providers to payers. To begin finding an answer, it’s critical to understand what “health equity” means.

Dayna Bowen Matthew, a professor at the University of Virginia School of Law and author of Just Medicine: A Cure for Racial Inequality in American Health Care, offers this definition: “Health equity is when regardless of race, ethnicity, gender and other non-clinical indicators, every patient has the opportunity to be healthy, receiving equal access and equal quality care.”

The way we pay for health care has everything to do with the way we deliver health care.

The definition is fairly simple, but the issue is complex and costly. In January, the National Academies of Science, Engineering and Medicine released a report that is part of a $10 million, five-year grant the agency received from the Robert Wood Johnson Foundation to study solutions that promote health equity. It identified nine factors that are the main drivers of health disparities: income and wealth, housing, health systems and services, employment, education, transportation, social environment, public safety and physical environment.

Deficiencies in these areas, known as the social determinants of health, may lead to poor health and to more expensive care because patients tend to be much sicker when they finally seek treatment. Consider these findings from the report:

  • Eliminating health disparities for minorities would have reduced direct medical care expenditures in the U.S. from 2003-2006 by $229.4 billion.
  • People with disabilities are more than twice as likely to not receive medical care because of cost.
  • The percentage of low-birthweight infants in the U.S. rose in 2015 for the first time in seven years. Low birthweight has been associated with inadequate prenatal care.
  • Compared with their urban counterparts, rural communities have higher rates of preventable conditions (such as obesity, diabetes, cancer and injury), and higher rates of high-risk health behaviors (such as smoking, physical inactivity, poor diet and limited use of seatbelts).

Dr. Derek J. Robinson, vice president of quality and accreditation for the five Blues plans, regularly sees the profound effect that social environment may have on health through his work as an emergency medicine doctor. He recalls one patient who had high blood pressure and diabetes and needed dialysis. The problem wasn’t the availability of dialysis in itself – it was the patient’s ability to get there because she was an amputee who did not have easily accessible transportation. By missing dialysis, that patient risked severe complications that could be both life-threatening and very costly.

“Where individuals live can predict their life expectancy, and it is startling that populations separated by just a few miles have many more years of life,” Dr. Robinson says. “To achieve health equity, we must recognize that variations in the social determinants of health exist and represent major opportunities to improve health.”

These factors include economic policies, healthy food, and safe space for living, education and recreation. Research has revealed lower quality care and health outcomes for women, not just  for disadvantaged racial and ethnic populations, Robinson added.

The value-based solution

Addressing the social determinants of health is an important piece of reducing health inequality, but the conversation must also be part of the emerging efforts between payers and providers to control costs.

Currently, racial health disparities alone are expected to cost health insurers about $102 billion per year. The insurance payment model has traditionally been based on fee-for-service: the insurer pays the provider for each visit, test and procedure. But increasingly, that system is being replaced in favor of value-based care models. Value-based care has many forms, but in general it means payment is tied to the quality and efficiency of the care provided.

What does this have to do with health equity? Everything, says Professor Matthew.

“The way we pay for health care has everything to do with the way we deliver health care,” she says. “Payers are becoming sensitive to the fact that if we change payment from per member per month – from instances of individual illness  –  to a more preventive and value-based payment, we also will make the changes that result in fewer deaths due to health disparities and lower costs due to health disparities.”

She says this concept also promotes collaboration among medical and non-medical entities to address the social issues that affect population health. For example, a housing organization and a medical group might work together because reliable housing often results in a healthier lifestyle.

“When payers incentivize the types of interventions that are not just medical, but also social, then payers will incentivize creative health care delivery changes that will reduce costs and improve health care delivery outcomes,” Matthew says.

The future of equity

Although health disparities run deep, there is reason to be hopeful these inequalities will diminish in the coming years, says Dr. Marshall Chin, a physician at the University of Chicago and director of the program office for the Robert Wood Johnson Foundation’s Finding Answers: Disparities Research for Change.

“This is a great time to be working on health equity,” Chin says. “People are realizing that equity is a huge problem and want to do something, but they haven’t known where to start. But now we know there are important measures that can be taken, such as measuring health disparities and then designing interventions to specifically meet them.”

He also supports funding for community health workers and other initiatives that may help people manage chronic conditions daily so they may avoid costly visits to their physician or the emergency department.

As these changes take shape for the future, Dr. Chin encourages health care professionals to work right now to reduce disparities in their own patient population. Clinicians should focus on listening closely to each patient, then develop an individual treatment plan that takes each patient’s social factors into account. They also may help their own organizations – whether it’s a practice, clinic or hospital – figure out how to address disparities in their patient population.

Ultimately, Dr. Chin says, health equity should be a goal for everyone.

“We collectively as a nation allow disparities to exist,” Dr. Chin says. “The impact of disparities on people’s lives is incredible. If someone is going to achieve the most they can in terms of their job, their productivity and their family life, they need to have their health. It’s the most basic thing.”

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