Blue Cross Equity Initiative Incentivizes Physicians to Close Care Gaps

"Data gaps and the lack of race data have been a challenge for years. Physicians can't do these kinds of interventions on their own," says BCBS-MA CMO Sandhya Rao.

Lagging, missing, and unstructured data is one kind of healthcare challenge. Some data, however, is hiding in plain sight, waiting to make a difference. One payer, BlueCross Blue Shield of Massachusetts (BCBS-MA), is focusing on existing HEDIS data to reveal multiple racial and ethnic disparities and link solutions to its current value-based purchasing (VBP) model. As reported in September by The Boston Globe, this initiative "will begin paying doctors more money if they close longstanding and pernicious gaps in care for people of color." Although the initiative has just begun, payers can consider what its design is already revealing as they seek to implement similar programs.

Equity begins at home

The initiative is rooted in two ideas and three program elements, according to Sandhya Rao, CMO for BCBS-MA.

"We've been aware of disparities for years and doing a lot to address them. But the events of 2020—including the murder of George Floyd and COVID-19—inspired us to look at our own HEDIS data across groups and to build on being at the forefront of value-based purchasing for more than a decade through our Alternative Quality Contracts (AQC)."

Linking current data, practice leadership, and payment approaches form the programmatic core of the plan's new disparities initiative.

How it will work

BCBS-MA will launch the initiative using publicly reported HEDIS data to identify the most critical gaps in care for members who are Asian, Black, and Hispanic. Early findings from the plan's 2021 Health Equity Report compared disparities in care across ethnic groups in the following areas:

• Colorectal screenings: Lower rates for Asian (67.0%), Black (63.8%), and Hispanic members (65.4%) versus non-Hispanic White members (70.8%).
   
• Adolescent well-care: Fewer visits by Black (68.9%) and Hispanic (70.3%) members compared to non-Hispanic White members (80.2%).
   
• Severe maternal morbidity: Rates were more than double for Black members versus White non-Hispanic (2.8% vs. 1.2%).
   
• Antidepressant medication management: Black and Hispanic members were 15%–20% less likely to receive the recommended management than White non-Hispanic members.

BCBS-MA will target these areas first, focusing on commercial members already attributed to its primary-care-focused AQCs, which more than 80% of BCBS-MA's physicians and hospitals participate in. Rao notes that the plan published these findings to “start the conversation” on how existing data can help identify disparities and how to address them.

BCBS-MA will use the AQC model to design incentives for its new equity-based initiative. "This is the part we know the least about now. We always start by sharing data and metrics for a few years to ensure those components are right, then build in incentives over time." This will begin in 2023, according to the plan.

To support providers in this new AQC direction, BCBS-MA is partnering with the Institute for Healthcare Improvement (IHI). The IHI will bring together plan practice leaders who are effective at sharing data to impact disparities and engaging other physicians to close gaps.

Measuring success and applicability for other plans

As to how BCBS-MA will know the initiative is working, Rao says that the plan will "start with the known, provide physicians with ongoing member reports, and refresh and refine the data as often as possible." 

Rao says that, based on existing data, the initiative may launch with different metrics for different physician groups and grow from there. "Our general quality strategy is to expand the measure set beyond HEDIS, such as behavioral health where we could use more measures of quality."

Common opportunities and challenges

As is true of many aspects of healthcare, opportunity and challenge are often rooted in the same elements.

"Data gaps and the lack of race data have been a challenge for years," says Rao. The health plan is using multiple approaches to overcome this, including working with providers and employers to collect data, and continuing to ask members to self-identify. The plan will also use imputed data (i.e., data that assumes a member's race based on multiple factors).

Supporting providers is another challenge. "Physicians can't do these kinds of interventions on their own," says Rao. Closely linked to this are BCBS-MA's AQCs, designed so that it "doesn't put all of the burden on the physician."

Paramount to this is whether the current AQC model has worked, given that it will be the chassis for the new program. A Harvard Medical School study published in The New England Journal of Medicine found that BCBS-MA's AQC "slowed the rate of medical spending growth by up to 12% while improving patient care" from 2009–2016 compared to averages nationally and across New England. On the quality and efficiency side, researchers noted that the AQC "has helped change the rates that physicians order tests and some imaging modalities, the rates of emergency department admissions, and the management of chronic conditions."

It is also true that an asterisk can be placed at the end of nearly every VBP result. These include other factors that could contribute to results, including "the presence of Medicare ACOs [accountable care organizations], payment reform among other commercial payers, and state policies," to name a few.

Understanding whether VBP can fully deliver is an ongoing question. Even the IHI's involvement in the new BCBS-MA equity initiative reinforces these challenges. Over the past 20 years, key IHI publications on quality and medical errors have revealed other truths hiding in plain sight: that healthcare was (and still is) struggling to meet its Triple Aim: better cost, outcomes, and customer experience.  

Here, Rao cites her colleague Dr. Mark Friedberg, SVP for performance measurement & improvement at BCBS-MA: "We can't just say we want to close these gaps without acknowledging the resource and effort involved."

And also without acknowledging existing data. As payers and other stakeholders look increasingly to alternative data sets from multiple external sources, BCBS-MA is using what it already has to bring into focus a story that was already there.