Can Healthcare Deserts Be Transformed Into Oases?July 23, 2022
Providing first-rate healthcare to underserved rural and urban communities is one of the great unmet challenges of recent decades. These low-income neighborhoods have been left behind and feel the pain of healthcare shortages most acutely.
The root of this problem is a misaligned system of incentives. Healthcare providers have had little financial motivation to offer primary care in neighborhoods with large numbers of uninsured people and those covered through Medicare and Medicaid. Without reliable access to routine primary care, patients living in these communities are also more likely to have untreated complex and chronic conditions.
The heart of this flawed set of incentives is the fee-for-service model of healthcare, which rewards physicians for providing large numbers of highly reimbursed medical services. This encourages a lot of short visits lasting 15 minutes or less where providers and patients are unable to build meaningful relationships, let alone the trust that keeps people healthy.
What’s needed is a system that rewards positive health outcomes rather than the number of services rendered. These superior models compel providers to make the extra financial investments needed to help chronically ill patients manage their diseases and help healthy patients stay that way.
Government officials have been placing greater emphasis lately on these improved models. The Centers for Medicare & Medicaid Services (CMS) recently requested information from healthcare stakeholders about how to effectively measure quality outcomes for patients in Medicare Advantage, with a focus on the Medicare star ratings system that rewards health plans for performance on certain measures such as quality of care and customer service.
CMS also asked for information from the public about how best to tailor payment systems to make sure that resources go to patients most in need of care. When linked to another recently announced CMS effort to move most Medicare beneficiaries into accountable and coordinated care relationships by 2030, an important new paradigm emerges: policy that allows so-called primary care deserts to become primary care oases.
Any update in government programs, however, needs to recognize that different Medicare beneficiaries have different needs. Beneficiaries with a lifetime of limited access to quality healthcare require more attention than recent retirees in good health. Star ratings also should be adjusted based on the social risk of the neighborhoods where beneficiaries live. This would eliminate overinvestment by Medicare in health plans that target higher income patients at the expense of lower income ones.
What would it mean for health outcomes if resources were tied to patients’ social conditions? It could mean that if patients are lonely, as many Medicare-age Americans are, they could be offered spaces for social activities. It could mean that if patients have mental or behavioral health concerns, they could have mental health professionals integrated into their primary care. It could mean that if patients lack healthy food or safe housing, social and community health workers can help them get what they need.
This is already happening thanks to the growing use of value-based care, which integrates preventive care, wellness, and mental health services to keep patients healthy rather than waiting until they’re sick. But more needs to be done to accelerate its uptake. The best way to do that is for Medicare to offer incentives to providers that target health outcomes, especially for socially complex patients, rather than count the individual services offered.
Government policy should encourage providers to consider and integrate social factors when they design care plans for their patients. Government should also incorporate data that track demographic factors, Medicaid status, and chronic conditions when setting reimbursement protocols.
Indices abound to do this, including the Social Vulnerability Index, which measures socioeconomic status, and the Social Deprivation Index, which gauges societal disadvantages. Federal agencies routinely utilize indices, including census data, to determine where to spend taxpayer dollars. Government healthcare spending should follow that long-established practice.
It is simply wrong that people in one neighborhood can expect to live 20 to 30 years less than people living just a few miles away. AARP estimates that the annual economic cost of such disparities in life expectancy will reach $1.6 trillion in 2030. That’s why Congress, federal agencies, and other stakeholders should work together to develop systems that deliver top care to all patients and to offer extra attention to Americans in underserved communities.