Health Care Transformation to Advance Health Equity

Health Care Transformation to Advance Health Equity

Given the wide expansion of value-based payment (VBP) health care transformation models in the United States, VBP can be a useful tool for reducing health inequities and advancing equity goals. VBP models provide additional flexibility to address social needs, structural determinants of health, and social determinants of health, such as services and care coordination that are not typically covered (but may be particularly important) for people experiencing worse outcomes due to socioeconomic status, race, ethnicity, social needs, or other  factors. Accordingly, many VBP models are now adopting a more intentional focus on equity. However, evidence suggests that VBP model uptake lags in marginalized populations, and sometimes may exacerbate disparities. Addressing equity through VBP remains a nascent field with diverse approaches, and limited evidence on which approaches work or help avoid undesirable outcomes. 

Below is a portfolio of work to inform health policymakers and stakeholders with practical implementation and policy guidance on how to improve health equity through VBP approaches.

Funding and support for this work has generously been provided by the Robert Wood Johnson Foundation, Bass Connections at Duke University, and the Duke-Margolis Center.


Accountable care value based purchasing

ACO REACH And Advancing Equity Through Value-Based Payment, Part 1

William K Bleser, Yolande Pokam Tchuisseu, Humphrey Shen, Andrea Thoumi, Chinmay Amin, Deborah R. Kaye, Mark B. McClellan, Robert S. Saunders, Health Affairs Forefront, May 2022

To inform health policy makers and stakeholders on approaches to achieve equity through VBP, we scanned the literature and reviewed various policy initiatives. We spoke with experts implementing equity-focused VBP models or with expertise on these models. In this article, we present a framework for categorizing the spectrum of approaches we identified for improving equity through VBP model design. Below and in part 2, we discuss the key design elements for explicitly addressing equity in ACO REACH; highlight examples (and evidence or early lessons, where available) of how some states and commercial payers have approached those same design elements; and identify additional opportunities for the Innovation Center and other parts of CMS, states, and commercial payers to continue to test ways to embed equity in VBP models.


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Improving health equity for older people with serious illness through value based payment reform

Improving Health Equity for Older People with Serious Illness through Value Based Payment Reform

Vishnukamal Golla, Nancy M. Allen Lapointe, Mina Silberberg, Virginia Wang, Trevor Lentz, Deborah Kaye, Corinna Sorenson, Robert Saunders, Brystana Kaufman, Journal of the American Geriatrics Society, April 2022

This articles provides four key considerations when designing value-based payment models, an increasingly used healthcare payment method for older adults.


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Case for investment in mobile health care

The Case For Investment In Mobile Health Care Solutions To Reduce Health Inequities

Keren Hendel, Health Affairs Forefront, April 2022


This article won the AcademyHealth Disparities Interest Group’s student essay contest. Students were asked to write an editorial on any health disparities topic of their choice, with a focus on the specific causes or consequences of disparities and/or solutions with the most potential to reduce disparities. The article was edited by Health Affairs Forefront in conjunction with the author.


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Pandemic-drive health policies to address social needs and health equity

Pandemic-Driven Health Policies to Address Social Needs and Health Equity

William K Bleser, Humphrey Shen, Hannah L Crook, Andrea Thoumi, Rushina Cholera, Jay Pearson, Rebecca Whitaker, Robert S. Saunders Health Affairs Policy Brief, March 2022


Stark disparities during the COVID-19 pandemic led to new health policy funding and interventions addressing social needs and social determinants of health to improve health equity. Lessons from these interventions and similar pre-pandemic initiatives can guide policy makers in designing more permanent approaches. 


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Covid inequities in older adults

Data Brief: Widened Racial Inequities in Underutilized Medicare Beneficiary COVID-19 Claims Files Illustrate Lifelong Structural Racism Exposure

William K Bleser,  Hannah L Crook, Andrea Thoumi, Rushina Cholera, Jay Pearson, Robert S. Saunders, Rebecca Whitaker, Mark B. McClellan, March 2022


This Duke-Margolis data brief uses these Medicare data to study COVID-19 inequities and their upstream causes. We first examine rates of COVID-19 cases and hospitalizations by race and ethnicity. We then compare these differences side-by-side as disparity rate ratios relative to non-Hispanic White beneficiaries. Caseload disparities ballooned into wider-than-expected hospitalization disparities for BIPOC populations. Widened caseload-hospitalization ratios are best described neither as “differences” nor “disparities” but rather as “inequities.”


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NC COVID19 Support Service Program

North Carolina’s COVID-19 Support Services Program: Lessons for Health Policy Programs to Address Social Needs

William K Bleser, Katie M. Huber, Hannah L Crook, Rebecca G. Whitaker, Jasmine Masand, James J. Zheng, Raman Nohria, Michelle J. Lyn, Robert S. Saunders, Milbank Memorial Fund, March 2022


We offer key recommendations to health policymakers (e.g., state health officials, commercial payers) creating or administering health policy programs to address social needs in local populations; our findings are also relevant to frontline implementers of such programs. 


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Bridging the health equity gap

Bridging The Health Equity Gap: Strategies To Create An Equitable Health System For Latinx Communities

Andrea Thoumi, Keren Hendel, Sebastian Gutierrez, Nikhil Chaudhry, Viviana Martinez-Bianchi, Health Affairs Forefront, November 2021


The experience of health systems providing COVID-19 testing and vaccinations in partnership with community organizations elucidated equity gaps in care delivery. We describe three key strategies for creating policies that embed health equity principles in their design and implementation to move us closer to an equitable health care system.


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Association of Unemployment with Medicaid Enrollment

Association of Unemployment with Medicaid Enrollment by Social Vulnerability in North Carolina during COVID-19

Paul R. Shafer, David M. Anderson, Rebecca Whitaker, Charlene A. Wong, Brad Wright, Health Affairs, September 2021


This article builds on the limited early evidence of the relationship between the pandemic and health insurance coverage, using county-level unemployment and Medicaid enrollment data from North Carolina, a large state that did not expand Medicaid. 


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How Are Payment Reforms Addressing Social Determinants of Health? Policy Implications and Next Steps

How Are Payment Reforms Addressing Social Determinants of Health? Policy Implications and Next Steps

Hannah L Crook, James Zheng, William K Bleser, Rebecca G. Whitaker, Jasmine Masand, Robert S. Saunders, Milbank Memorial Fund, February 2021


This issue brief summarizes the current landscape of payment reform initiatives addressing SDoH, drawing on results from a systematic review of peer-reviewed and gray literature supplemented with scans of state health policies and proposed payment reform models. It also discusses challenges and opportunities related to implementation — data collection and sharing, social risk factor adjustment (statistical methods for accounting for adverse social conditions associated with poor health), cross-sector partnerships, and organizational competencies — as well as policy implications and next steps so that states and payers can use value-based payment to encourage and promote addressing social needs.


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Pediatric accountable health communities: Insights on needed capabilities and potential solutions

Pediatric accountable health communities: Insights on needed capabilities and potential solutions

Gary Wang, Heather Frank, Taruni Santanam, Erica Zeng, Madhulika Vulimiri, Mark McClellan, Charlene Wong, Healthcare, December 2020

Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. We aimed to identify needed capabilities and potential solutions for implementing pediatric AHCs. Pediatric AHCs could provide more integrated, high-value care for children. Respondents highlighted the need for shared infrastructure and cross-sector alignment of measures and financing. 

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Health Equity Should be a Key Value in VBP

Health Equity Should Be A Key Value In Value-Based Payment And Delivery Reform

Sahil Sandhu, Robert S. Saunders, Mark B. McClellan, Charlene A. Wong, Health Affairs Forefront, November 2020

Value-based payment (VBP) structures have the potential to reduce health disparities, and during the pandemic, health care organizations with VBP models have had greater flexibility to effectively pivot their care delivery. However, too few organizations are actively prioritizing equity in their VBP models. We outline three strategies for payers and providers to embrace health equity in VBP design and implementation.


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Duke-Margolis Team

Nancy Allen Lapointe

Nancy Allen LaPointe

Faculty Fellow, Duke-Margolis Center for Health Policy
Adjunct Associate Professor in the Department of Medicine Faculty


David Anderson

Research Associate, Health Policy Evidence Hub

William K. Bleser - Margolis headhot

William K. Bleser, PhD, MSPH

Assistant Research Director, Health Care Transformation for Population Health, Social Needs, and Health Equity
Senior Team Member
Anti-Racism and Equity Committee Member

pic of nikhil

Nikhil Chaudhry

2021 Margolis Intern

Picture of Rushina Cholera

Rushina Cholera, MD

Medical Instructor in the Department of Pediatrics
2020 Intern Mentor
Anti-Racism and Equity Committee Member

Katie Huber

Katie Huber, MPH

Policy Analyst


Brystana Kaufman, MSPH, PhD

Assistant Professor, Population Health Sciences
Margolis Core Faculty Member

Deborah Kaye

Deborah Kaye, MD

Assistant Professor of Surgery
Margolis Core Faculty

Trevor Lentz

Trevor Lentz, PhD

Assistant Professor in Orthopaedic Surgery
Margolis Core Faculty

Mark McClellan

Mark McClellan, MD, PhD

Director of Margolis Center
Robert J. Margolis, MD, Professor of Business, Medicine and Policy
Margolis Executive Core Faculty

Picture of Jasmine Masand

Jasmine Masand, (MPP '21)

Anti-Racism and Equity Committee Member

Sahil Sandhu

Sahil Sandhu

2020 Margolis Intern

Robert Saunders

Robert Saunders, PhD

Senior Research Director, Health Care Transformation
Adjunct Associate Professor
Senior Team Member
Margolis Core Faculty

Humphrey Shen Headshot

Humphrey Shen

Research Assistant

Mina Silberberg

Mina Silberberg, PhD

Associate Professor in Family Medicine and Community Health
Margolis Core Faculty

Corinna Sorenson

Corinna Sorenson, PhD

Director of Graduate Education Initiatives and the Margolis Scholars Program
Assistant Professor in Population Health Sciences
Margolis Core Faculty
Anti-Racism and Equity Committee Member

Andrea Thoumi

Andrea Thoumi, MPP, MSc

Health Equity Policy Fellow
Senior Team Member
Anti-Racism and Equity Committee Member
Core Faculty Member
Adjunct Assistant Professor
2020 Intern Mentor


Rebecca Whitaker, PhD, MSPH

Assistant Research Director, North Carolina Health Care Transformation
Senior Team Member
Anti-Racism and Equity Committee Member

Virginia Wang

Virginia Wang, PhD

Associate Professor in Population Health Sciences
Margolis Core Faculty

Charlene Wong

Charlene Wong, MD, MSHP

Assistant Professor of Pediatrics
Margolis Core Faculty
2020 Intern Mentor

James Zheng

James Zheng

2020 Margolis Intern
2021 Margolis Intern