Health care companies and organizations across the country are grappling with health inequities, spurred by devastating disparities in the pandemic’s toll as well as the overdue reckoning with racial injustice that has followed the murder of George Floyd.
Some have been at this for a while. Others are just beginning. But all have a lot of work to do.
We work for Blue Cross Blue Shield of Massachusetts (BCBSMA), a not-for-profit private health plan that has long made diversity, equity, and inclusion a priority in its business, hiring and corporate culture, and community work. But directly addressing the racial inequities in health care had not been part of the company’s core work as an insurer.
To address that, our organization recently launched the Commonwealth of Massachusetts’ first collaborative effort between a health plan and the medical community designed specifically to eliminate health inequities. Its goal is to improve health care for all plan members across every racial and ethnic group.
Because we know other plans are eager to address inequities as well, we are sharing the approaches taken so far.
Start fixing health inequity with data collection
Data collection is a challenging and laborious process. So when there is longstanding evidence that racial and ethnic minority populations have received lower-quality health care in the U.S., it is tempting to jump straight to solutions without first measuring disparities locally.
That’s a mistake. Without local data, it is impossible to be accountable for meaningful, sustainable improvement over time in the communities being served.
Our health plan faced immediate hurdles in this first step. Race and ethnicity data were lacking for more than 90% of members. So our organization began inviting members to self-report their race and ethnicity, supplementing that with data shared by employer customers and health systems.
Because we did not want a lack of perfect data to slow progress, we imputed member race and ethnicity data using the RAND Bayesian Improved Surname Geocoding method, a commonly used approach when self-reported data are incomplete. This method uses a person’s surname in the U.S. Census and the racial and ethnic composition of their neighborhood to produce a set of probabilities that an individual belongs to one of a set of mutually exclusive racial and ethnic groups. To be sure, analyses based on imputed data likely underestimate the true magnitude of inequities, but they are a good starting point and can be used to begin addressing the inequities they identify.
Share the data. A health plan can’t address inequities addressed in a vacuum. We began sharing confidential reports with large health systems in our coverage network in the summer of 2021, showing each the inequities in care within their organizations — for example, whether Black patients were receiving appropriate medication to control asthma attacks at the same rate as white patients — and how they compare with patients in other health systems.
BCBSMA will be making reports available to its employer customers too, showing disparities in care between employees of different races. As a health plan, the impetus for doing this is clear: Customers pay the same amount for health insurance regardless of their race, ethnicity, or neighborhood, and should receive equally high-quality care. That’s a business as well as a moral imperative.
Let findings spur improvements
Our company has made data regarding inequities in care publicly available so it can be of use to the broader community, which can hold BCBSMA accountable for improvement over time. Drawing on 2019 data for 1.3 million of our commercial members in Massachusetts, our analysts looked at 48 measures widely used to monitor performance on important dimensions of health care and found stark disparities in the vast majority of measures.
For example, Asian, Black, and Hispanic members were less likely than white non-Hispanic members to be screened for colorectal cancer. Rates of life-threatening medical issues during childbirth for Black health plan members were more than double those of white non-Hispanic members. And Black and Hispanic members were 15% to 20% less likely than white non-Hispanic members to receive recommended management of antidepressant medications.
Such disparities are pervasive in American health care. But these are humbling results for a health plan that has long been committed to quality, affordable care for all of its members.
These findings are galvanizing our organization to do better. Equity of care is now a fourth strategic priority for our company, on par and equal in status with quality care, affordable care, and an unparalleled consumer experience.
Collaborate with the medical community
BCBSMA has collaborated for more than a decade with health systems via its Alternative Quality Contract, which replaced the fee-for-service model and instead supports and rewards clinicians’ efforts to improve the quality and value of the care they deliver.
Our company is now building on that model, in concert with the Institute for Healthcare Improvement, to help health systems in our value-based payment programs improve care equity with a newly established collaborative. Working together, we will determine how best to measure inequities in both access and care, and will create programs designed to eliminate those inequities.
We will also create new contracts that reward clinicians for providing care that is equal in quality for people of all races and ethnicities. We know clinicians want to eliminate inequities in care, and these contracts will give them a business case to do so, just as our payment models have long been structured to reward clinicians’ efforts to improve quality and value.
Equity is the unfinished business of health care reform
The inequities that our organization and many others are working to address are centuries old and extend far beyond health care. But we believe that health plans, in collaboration with their members, employer customers, community partners, and the medical community, can make meaningful changes to reduce them.
As a first step, health plans and other payers can do what BCBSMA has done — calculate their own quality measures, produce internal health equity reports based on those measures, and publish those reports. That will enhance the ability of insurers to be accountable for improving the quality of care for everyone in their health system. And by building equity measures into their incentive programs, payers can support the medical community in closing equity gaps.
The past 20 months have been a constant reminder that health care does not exist in a silo — it affects our economy, our schools, our mental health and national health. Eliminating disparities in health care helps create healthier, more productive, and more resilient communities and workplaces, and ensures that health plans meet their commitment to provide high-quality coverage for all of their members.
In recent years, health plans and the medical community have made strides in expanding access to health care and health coverage, and have worked to improve quality and safety. It is now time — long past time — to include racial inequities at the center of the work to create a better health system.
Andrew Dreyfus is president and CEO of Blue Cross Blue Shield of Massachusetts. Sandhya Rao is an internist and BCBSMA’s chief medical officer and senior vice president.