Vvalue-based care champions health and justice by focusing on outcomes rather than units of service. As this type of payments reform develops, implementing the changes needed to enable it must operate within a framework of fairness rather than equality.

Work towards equality means giving different groups the same opportunities, while working to equity means giving different groups different opportunities according to their needs. Health equity requires recognizing that health care systems deliver different outcomes for different populations due to underlying systemic differences, so solutions for improving health and health care must also be different.

Commitment to reducing disparities in care for populations affected by racism and other systemic disadvantages has grown in recent years. However, the successes have been very variable, and have sometimes even widened the disparities. Some payers and policymakers moving to value-based reimbursement remain stuck in an equal mindset, treating all health systems the same rather than acknowledging the disparate starting points of this transition. This is a major impediment to progress towards a truly equitable health care environment.

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In a recent JAMA Viewpoint article, Amol Navathe, Pooja Chandrashekar, and Christopher Chen explored ways to make value-based payments work for Federally Qualified Health Centers (FQHCs). These are community clinics that receive federal funds to treat historically disadvantaged populations. Value-based payments that treat these centers like any other primary care clinic, without recognizing or addressing the real complexities of serving very difficult patient populations, will not move the needle to true equity in health.

Navathe and his co-authors described policy directions that could enable federally licensed health centers to increase health equity through value-based payments by increasing funding to address the social drivers of health, providing care in the community with a local workforce and improving quality measurement. The achievement of these political objectives strongly depends on the way in which they are implemented.

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Create flexibility with innovative value-based payment solutions

A step towards value-based care is a forward-looking payment system: enhanced upfront payments untied to billing for a specific service that aim to address the social drivers of health as well as barriers to access and compliance.

But if payments are based on patients who actually visit the clinic, it creates a trap for federally qualified health centers because they serve more patients who find it harder to get to appointments. Populations with less access to efficient transportation, less flexibility to leave work or caregiving duties, and less able to navigate the healthcare system may not be able to make or keep appointments. It is absurd that federally licensed health centers cannot be paid to help patients overcome barriers to care unless patients first overcome those barriers themselves so that their visits “count” .

One solution is to decouple payments related to social drivers of health from visits-based payments. Small-area indices, such as the Area Deprivation Index, measure the relative difference in many social factors of health between populations based on geographic census tracts of approximately 4,000 people. The data is publicly available and does not require increased resources for data collection practices or office visits for patients. Providing dedicated funding for the social drivers of health informed by these regional indices is a promising way to ensure that disadvantaged communities get the support they need to engage more holistically in the health care system.

Filter individuals only when it meets their needs

Screening for social needs during a primary care visit has some drawbacks. Patients report that it can be demeaning to ask providers to collect data about their social challenges, and the process can be re-traumatizing or even abusive if providers do not have the resources to address the issues revealed. Providers said universal screening for social conditions they cannot address takes time to address the pressing concerns of patients and their families. Both perspectives recognize that implementing universal screening for social drivers of health without concordant response capacity could widen health disparities rather than narrow them.

Policies should require federally qualified health centers to select at the individual level only those vulnerabilities they are capable of addressing, while continuing to guide payments for these centers based on population-level metrics using publicly available data such as area deprivation index, combined with age and disease burden data.

A fair payment system should also recognize that federally licensed health centers should work to earn the trust of patients rather than assuming that trust exists. The populations most historically discriminated against are the least likely to trust health systems. Black Americans, for example, may be less likely than others to trust a health center with their race and ethnicity data.

This has a trickle down effect for value-based payment. Payments based on health systems collecting data on race and ethnicity will disproportionately disadvantage health systems where lack of trust is already prevalent and could have the unintended consequences of exacerbating disparities. Again, using publicly available data at the population level would relieve federally licensed health centers of the need to collect data that patients may not yet want to share.

Empowering patients and communities with person-centered care

The delivery of value-based, person-centred care must embrace the idea that time belongs to patients, not to the healthcare system. Working toward greater health equity means creating systems that take it seriously. Disadvantaged people often have to use more of their personal time to accomplish the same tasks as advantaged populations, such as transportation or obtaining food.

Values-based care that enhances care at home and in the community improves access and adherence, and provides respectful and culturally competent services through a workforce representative of the community is essential to ensure a fairer system that reduces disparities.

Standardize the rules of the game for FQHCs

Federally licensed health centers are not the same as other primary care clinics. They typically serve a high proportion of people without insurance or covered by Medicaid. These people are already more burdened by disease and social risk factors which, in turn, drive up medical costs. This means that fundamental calculations like the medical loss rate, a measure of how much of the money spent on care is used to provide that care, will have to be higher in value-based care arrangements because it costs more expensive to care for patients who are already over-burdened.

Setting a lower target for medical loss rate that is “equal” with other provider systems will undermine fairness for federally qualified health centers in value-based contracts and perpetuate the discrimination inherent in the current system. . Instead, value-based contracts must meet these centers where they are, clinically and financially. This means setting goals that will give FQHCs a fair chance to earn shared savings, improve their financial viability, and continue to serve their communities.

Lora Council is a family and preventive medicine physician and chief population health officer at Yuvo Healthwhich provides administrative and contracted managed care services to federally licensed health centers.