Striving for Equity in Access to and Use of Specialty Care

This post originally appeared on Health Affairs Blog

In 2015 the Bristol-Myers Squibb Foundation launched a grant-making initiative called Specialty Care for Vulnerable Populations to address inequities in access to, and utilization of, specialty care services in the United States.

The goal of this national initiative is to catalyze sustainable improvement and expansion of specialty care service delivery by safety-net providers, so as to achieve optimal and more equitable outcomes for the people they serve who are living with complex diseases such as cancers, cardiovascular diseases, and HIV/AIDS. Funding and partnerships focus on efforts to complete systems of care through specialty–primary care collaborations and to integrate patient engagement, navigation, and social support services.

Poor access to timely, high-quality specialty care causes thousands of preventable deaths each year, particularly among low-income, minority, and rural populations who are fighting serious diseases. Studies suggest that eliminating racial disparities in cancer care alone would result in 250,000 fewer cancer deaths annually.

In addition to this tremendous health impact, eliminating racial disparities in cancer care would also result in $2.3 billion in annual, direct health care savings from earlier diagnosis and treatment and reduced emergency department use and reduced hospital readmission after treatment.

While the primary care field, and community health centers in particular, have long acknowledged the impact of nonmedical, social determinants of health on patients and the importance of inclusiveness and equity in health care delivery, the specialty care field has largely lagged behind in addressing these issues.

Now is a particularly opportune time for changing this because of the concurrence of the expansion of access to health care for Americans under the Affordable Care Act; “big data” insights about population health and health inequities; transformative innovations in medicine and public health; and energized health and social justice movements in the United States. These forces can be aligned to drive the development and scaling of solutions to improve outcomes for vulnerable and medically underserved people in need of specialty care. This is also an opportunity for the specialty care sector to expand the impact of its extraordinary expertise in treatment and care.

Funding Early Innovators

As a first step to address this need, the Bristol-Myers Squibb Foundation invested in a number of exceptional organizations that are on the front lines and the front edge of mitigating disparities in specialty care. The Ralph Lauren Center for Cancer Care in East Harlem, New York; the Anne Arundel Medical Center in Annapolis, Maryland; and Maine Medical Center in Portland, Maine—are coming up with new ways to move on new evidence-based guidelines issued by the U.S. Preventive Services Task Force and are hoping to use reimbursement by the Centers for Medicare and Medicaid Services (CMS) and private payers to roll out lung cancer screening of low-income, minority, and rural smokers who are at high risk.

The Association of Community Cancer Centers is working with its members to develop a model for early patient engagement and care coordination for lung cancer patients covered by Medicaid.

Farmworker Justice is establishing community prevention and care networks that encompass use of workplace outreach, migrant health clinics, and National Cancer Institute Comprehensive Cancer Centers to serve migrant farmworkers at high risk for melanoma and other skin cancers in Florida and California.

Project ECHO has received a planning grant to explore the application of its telementoring and collaborative care model to cancer care.

And finally, for HIV/AIDS, the Washington AIDS Partnership is inclusively pursuing the 90-90-90 HIV/AIDS strategy (that is, 90 percent of patients tested/90 percent treated/90 percent at undetectable viral load) to end the epidemic in the District of Columbia by reaching into the community and testing a model of home-based care to increase antiretroviral adherence and viral suppression among people who have fallen out of clinical care.

More than Funding to Make Change Stick

In supporting the development of innovative models of specialty care delivery, the foundation is also helping the grantees to sustain new services and capacities beyond the grant period by means of reimbursement from payers; other funding sources; and policy change.

To this end, and taking into account the moving targets of health care finance reform and integrated service delivery systems, we have engaged two strategic partners to provide one-on-one, real-time, real-project, technical assistance to the grantees. FSG, a nonprofit, mission-driven, strategy and research consulting firm for social change, is helping grantees to identify and engage the health plans and health care systems that cover and serve their projects’ target populations. Interaction with payers, health plans, and health care system leadership is new for many grantees—just as it is for the foundation. But it provides the opportunity to explore pathways for reimbursement or alternative financing, such as hospital community benefit, and to understand what health systems and health plans see as essential and compelling to demonstrate and include in evaluation plans, such as health services use analysis.

The Center for Health Law and Policy Innovation, a law clinic at Harvard Law School that advocates for legal, regulatory, and policy reforms, is creating for the grantees tailored policy and advocacy road maps that use strategies ranging from pursuing state Medicaid amendments for new patient care and nonmedical social support models, to advocating for broader CMS reimbursement of telemedicine services in rural areas, to policymaker education about migrant health care services.

Encouraging an Equity Mindset and Coordinated Actions in Specialty Care

The Bristol-Myers Squibb Foundation has also found that a critical area of work is sharing data about inequities in specialty care and emerging best practices with providers, payers, patient advocates, policymakers, and philanthropic funders and encouraging them to adopt an equity mindset and to take coordinated action together. Earlier this summer, we launched a new resource for the field—Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost. Developed in partnership with FSG, this series of 5 issue briefs lays out the state of inequities in specialty care; details effective strategies and solutions for improving health equity by mentioning relevant case studies; and provides implementation guidance for the field. The three core strategies are increasing availability of specialty care, ensuring high-quality care, and helping patients engage in their care.

Our ambition is nothing short of sector-wide change that puts equity on the agenda of all health care providers and stakeholders in specialty care. For our part at the Bristol-Myers Squibb Foundation, we will continue to share lessons and evidence with the field as the grantees’ work progresses. We welcome opportunities to learn, partner, and collaborate with the aim of eliminating disparities and creating the conditions for optimal and equitable specialty care for all.

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