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The Importance of Race and Ethnicity in Accounting for Social Risks in Medicare Value- Based Payments April 3, 2019 Maddy Shea, Judy Ng, and Kima Taylor 1 Judy Ng, PhD, NCQA, Research Scientist 2 Kima Taylor, MD, MPH, Managing Principal,


  1. The Importance of Race and Ethnicity in Accounting for Social Risks in Medicare Value- Based Payments April 3, 2019 Maddy Shea, Judy Ng, and Kima Taylor 1

  2. Judy Ng, PhD, NCQA, Research Scientist 2

  3. Kima Taylor, MD, MPH, Managing Principal, Anka Consulting 3

  4. Maddy Shea, PhD, Principal, HMA Community Strategies 4

  5. Presentation Overview ❑ Background ❑ How Race and Ethnicity Influences Health ❑ Remedies to Racial and Ethnic Risks ❑ Q & A 5

  6. Seismic Impact of Shift to Value Based Care Insert Cover of ASPE Report here This Photo by Unknown Author is licensed under CC BY-SA-NC 6

  7. Introduction • Emerging concepts on the contribution of minority status to health disparities: Minority stress, Resilience, Epigenetics, Life course • Understanding the contribution of minority status to disparities is critical: • Parse out role of different risk factors Background • Understand underlying mechanisms • Target interventions, modifiable pathways • Inform payment and delivery models 7

  8. Assessment • Understand evidence supporting concepts, how they may work together, and policy implications Goal • What is the concept? How is it operationalized (mechanism of action)? Strength of evidence? Questions 8

  9. How might concepts work together? Life Course Minority Stress Health and Epigenetics Quality of Life Resilience 9 9

  10. Minority Stress Definition/Operationalization Mechanism Factors that may influence of Action pathway between • The chronic stress resulting from discrimination and health experiences of unfair treatment and include perception of abusive behavior related to one’s discrimination as stressful, belonging to a stigmatized minority and coping responses that group. may moderate health. • Most well-understood causes of Strength of Individual studies suggest minority stress are prejudice & Evidence association between discrimination, which affects health minority stress and health via activation of fight/flight response disparities, but systematic (increases blood pressure, cortisol), reviews did not or health behavior (unhealthy demonstrate link. drinking, eating). 10 10

  11. Min inorit ity St Stress Source: https://washingtonmonthly.com/magazine/janfeb-2014/driving-while-black/ 11

  12. Min inorit ity St Stress Source: http://www.racismreview.com/blog/category/native-american/ 12

  13. Min inorit ity St Stress Source: https://www.theatlantic.com/notes/2016/07/a-single-photo-that-captures-race-and-policing-in-america/490664/ 13

  14. Min inorit ity St Stress Source: http://www.badnewsaboutchristianity.com/gab_racism.htm 14

  15. Resilience Mechanism Resilience-related, Definition/Operationalization of Action protective factors include • Generally refers to positive resources (social support) that facilitate resilience, or adaptation (doing well) despite traits (optimism). adversity, trauma, threat, but lack of universal definition. Common Vulnerability factors (urban concepts include: poverty) may moderate • Recovering or bouncing back resilience effects. from adversity Strength of Multiple studies on role of • Rising above adversity Evidence resilience in moderating • Adaptation/adjustment process disparities in vulnerable • Lower incidence of mental groups, but systematic health issues after adversity. reviews demonstrating link between resilience and disparities are limited. 15 15

  16. Resi silie lience Source: https://www.npr.org/sections/health-shots/2017/07/15/536657455/moms-need-social-support-and- not-just-in-the-baby-years 16

  17. Resi silie lience Source: https://www.lynda.com/Business-tutorials/Enhancing-Resilience/718618-2.html 17

  18. Epigenetics Mechanism Factors influencing of Action epigenetic regulation Definition/Operationalization include: Maternal behaviors during • Study of changes in gene expression pregnancy, paternal health, (phenotype) regulated by the social interaction, diet and epigenome: the modifiers (biological exercise, environmental processes such as DNA methylation) chemicals. that direct DNA expression. Strength of Evidence on regulation of Evidence specific genes for health • Modifiers can be altered by social, outcomes (e.g., cancer), cultural, psychological, physical, but systematic environmental exposures. reviews/meta-analyses evidence on link between epigenetics and disparities is limited. 18 18

  19. Epigenetics Source: https://harvardmagazine.com/2017/05/is-epigenetics-inherited 19

  20. Epigenetics Source: https://harvardmagazine.com/2017/05/is-epigenetics-inherited 20

  21. Life Course Definition/Operationalization Mechanism Acknowledges importance Health is: of Action of various factors that may • Shaped over time interact over time to affect • Affected by multiple factors health. (social, cultural, physical, other) Strength of Compelling evidence to Evidence support life course Overarching framework to understand perspective, mostly on how experiences or exposures affect early life socioeconomic health through life. conditions and adult health. Sub-concepts include: sensitive Evidence on causal periods, accumulation effect, linked mechanism limited. lives. 21 21

  22. Lif ife Course Source:http://www.worcestershire.gov.uk/download/downloads/id/10484/2018_briefing_on_adverse_childhood_experienc es.pdf 22

  23. How might concepts work together? Life Course Minority Stress Health and Epigenetics Quality of Life Resilience 23 23

  24. In Sum Concepts relevant for understanding disparities & may work together to undergird disparities But all have literature gaps that we can work together to address Food for thought: In ignoring race and ethnicity, do we disadvantage providers serving a high-proportion of minorities? And their patients? 24 24

  25. Policy Implications Consider Consider Minority status Resilience addresses range of experiences may be proxy for traits, processes, factors that throughout life discrimination & factors that may influence minority stress interact & confer health health advantage → Intervention opportunities 25 25

  26. Getting into Action ✓ Collect standardized self reported race and ethnicity data for all individuals ✓ Reduce minority stress ✓ Build resilience ✓ Prevent and mitigate harms early in the life course 26

  27. Questions? 27

  28. Resources • Explaining the Relationship Between Minority Group Status and Health Disparities: A Review of Selected Concepts Judy H. Ng, Lauren M. Ward, Madeleine Shea, Liz Hart, Paul Guerino, and Sarah Hudson Scholle, Health Equity, March 2019 • ASPE Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs - A Report Required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 https://aspe.hhs.gov/pdf- report/report-congress-social-risk-factors-and-performance-under-medicares-value- based-purchasing-programs • Accounting for Social Risk Factors in Medicare Payment http://nationalacademies.org/hmd/Activities/Quality/Accounting-SES-in-Medicare- Payment-Programs/Medicare-Social-Risk-Factors-Overview • National CLAS Standards-Office of Minority Health https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53 • Advancing Health Equity At Every Point of Contact https://www.thinkculturalhealth.hhs.gov/ 28

  29. Contact Information Maddy Shea, HMA Community Strategies mshea@healthmanagement.com Judy Ng, NCQA ng@ncqa.org Kima Taylor, Anka Consulting kimataylor@ankaconsultingllc.com 29

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