Promoting Health Equity And Eliminating Disparities Through Performance Measurement And Payment
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Abstract:
Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.Keywords:
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Health policies are regarded as a governance mechanism crucial for reducing health inequity and improving overall health outcomes. Policies that address chronic conditions or health inequity suggest a governance shift toward active health over past decades. However, the current literature in health policy largely focused on some specific health policy changes and their tangible outcomes, or on specific inequality of health policies in gender, age, racial, or economic status, short of comprehensively responding to and addressing the shift. This is exacerbated further by a common confusion that equates health policy with health care policy, which has been burdened by increased population ageing, growing inequalities, rising expenditures, and growing social expectations. This study conducted a narrative literature review to comprehensively and critically analyze the most current knowledge on health policy in order to help us establish a theoretical framework on active health governance. The comprehensive framework proposed in this paper identifies the main elements of a well-defined active health governance and the interactions between these elements. The proposed framework is composed of four elements (governance for health, social determinants of health, lifestyle determinants of health, and health system) and three approaches (whole-of-government approach, whole-of-society approach, and lifespan/life-course approach) that are dynamically interacted to achieve two active health outcomes (health equity and health improvement). The framework provides a conceptual solution to the issues of current literature on health policy and practically serves as a new guide for health policymaking.
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The WHO views health systems as all the activities which aim at promoting, restoring, or maintaining health. For the benefit of mankind, WHO's 'Health for All and All for Health' concept serves as strategic, far-reaching, and guiding vision for various stakeholders of health. Government policymakers should take this concept seriously when formulating and implementing health policies, improving health systems, as well as maintaining health equity. To achieve equitable health services, it is also essential for policymakers to consider structural determinants of health such as health system, public policies, resource allocation, cultural and social values, socioeconomic status, gender, and health literacy. Health literacy becomes an important public health goal for alleviating health inequalities within societies. This chapter outlines the equity of health systems and health resources, social determinants of health, definitions, and roles of health literacy, as well as the relationship between health systems, health literacy, and health equity. Policy initiatives, such as improvement of health system, tackling health literacy at multiple levels, sharing of responsibility among stakeholders, formulation of literacy-specific populational policies, as well as strengthening of support for research on health literacy, are recommended.
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Issue addressed: Health policy in Australia, including that related to illness prevention and health promotion is increasingly focussed on evidence of health outcomes. Although there is evidence of gains in the health status of the Australian population, these have not been shared evenly by all population groups, leading to increased inequalities in health. To date, the health outcomes approach and the research used to inform that approach has given little consideration to variations in outcomes among populations and the implications for equity. Methods: A literature review and critical analysis were undertaken. Results: Although the health outcomes approach has not addressed the issue of equity goals explicitly, there is an implicit endorsement of the position that all health gains should be valued equally, irrespective of who gains. The pursuit of maximum health outcomes may lead to widening gaps between the advantaged and disadvantaged in our society. Conclusion: There is a need for all health outcomes initiatives to explicitly address equity considerations. This requires monitoring health staus differentials within populations and analysing variations in the effectiveness of interventions. A new program of research focussed on what works to improve health specifically in disadvantaged groups, rather than considering the effectiveness of interventions in isolation from their context, would provide the evidence-base for health policy concerned with inequalities in health. (author abstract)
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Achieving health equity is a national priority in the United States and having a public health workforce equipped to make health policy and administrative decisions that reduce disparities is needed. We examined 50 schools that offered an on-campus Master of Public Health and are accredited by the Council on Education for Public Health with concentrations or tracks in health policy and management (HPM). Nationally, only 6 (12%) HPM tracks required students to take a course in health equity and/or disparities. Of the optional courses offered within HPM tracks, 30.5% were focused on specific health conditions, and 28% were focused on broadly defined inequities. A smaller portion of health equity courses covered topics in sexual and reproductive health (5.1%), women and gender (3.4%), immigration (1.7%), and LGBTQ populations (1.7%). If health equity is to be achieved in health policy and management, educating all students earning a Master of Public Health in HPM tracks on these issues and equipping them with competencies to effectively tackle health inequity is a starting place.
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Public health policy approaches have demonstrated measurable improvements in population health. Yet, "one-size-fits-all" approaches do not necessarily impact all populations equally and, in some cases, can widen existing disparities. It has been argued that interventions, including policy interventions, can have the greatest impact when they target the social determinants of health. The intent of this article was to describe how selected current policies and policy areas that have a health equity orientation are being used with the aim of reducing health disparities and to illustrate contemporary approaches that can be applied broadly to a variety of program areas to advance health equity. Applying a health equity lens to a Health in All Policies approach is described as a means to develop policies across sectors with the explicit goal of improving health for all while reducing health inequities. Health equity impact assessment is described as a tool that can be effective in prospectively building health equity into policy planning. The discussion suggests that eliminating health inequities will benefit from a deliberate focus on health equity by public health agencies working with other sectors that impact health outcomes.
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The tremendous increase in knowledge on inequities in health and their drivers in recent decades has not been matched by improvements in health inequities themselves, or by systematic evidence of what works to reduce health inequities. Within health equity research there is a skew towards diagnostic studies in comparison to intervention studies showing evidence of how interventions can reduce disparities. The lack of sufficient specific evidence on how to implement specific policies and interventions in specific contexts to reduce health inequities creates policy confusion and partly explains the lack of progress on health inequities. In the field of research on equity in health, the time has come to stop focusing so much energy on prevalence and pathways, and instead shift to proposing and testing solutions. Four promising approaches to do so are implementation research, natural experimental policy studies, research on buy-in by policy-makers to action on health inequities, and geospatial analysis. The case for action on social determinants and health inequities has well and truly been made. The community of researchers on health equity now need to turn their attention to supporting implementation efforts towards achievements of the Sustainable Development Goals and substantive reductions in health inequities.
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Considering that health inequalities derive from socioeconomic inequalities, fair policies and strategies to tackle health inequalities must focus on socioeconomic conditions. What is needed here is Health in All Policies, a comprehensive and intersectoral approach beyond health and healthcare sectors. However, based on a review of policies and programs of the Ministry of Health and Welfare and the 3rd National Health Promotion Strategies (Health Plan 2020) in Korea, we conclude that they totally lacked in perspective on health equity and social determinants of health. In fact, even most programs under the name of health equity include only supplementary health services targeted for low-income groups. As socioeconomic inequalities are worsening in Korea, health inequalities are more likely to be further aggravated if timely actions are not taken.
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Disparities in healthcare represent a failure in the equity domain of quality. Although disparities have been well documented, little has been written about how hospitals might use improved data collection and quality improvement techniques to eliminate disparities. This article describes early findings from the planning phase of the first hospital-based disparities collaborative. The authors also discuss the changes in policy and practice that may speed hospitals in placing disparities and equity on their quality agendas.
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