Measuring Healthcare Equity in North Carolina

Last month, healthcare leaders in North Carolina announced that they are developing an index to measure health inequities across the state. The index is intended to enable partners in the state to better understand health data, which can then support their efforts to improve health outcomes. Realizing this vision, however, requires that the index takes into account community perspectives on measurement and healthcare accountability.

The coalition, convened by the Blue Cross and Blue Shield of California Foundation, includes healthcare organizations, the state’s American Indian Health Board, and the Association of Mexicans. They intend to release the first version of the index by the year’s end.

This effort complements several shifts in North Carolina’s health policy and practices over the past decade. In 2015, the state legislature passed legislation directing the North Carolina Department of Health and Human Services to transition away from its state-run, fee-for-service Medicaid program. Instead, the state is implementing managed care, under which the state contracts with health insurance companies. These state contracts provide a set amount of money, known as capitated payments, based roughly on the number of people the company covers. The companies are then on the hook for covering costs and services for their members within that budget.

This move follows similar shifts made across the country as a result of the 2008 Affordable Care Act. That bill incentivized healthcare payors and providers to focus on value to patients rather than the volume of services. As a result, these institutions are increasingly prioritizing preventive care and investing in community health efforts to meet patient needs.

In addition to Medicaid transformation, North Carolina recently launched its Healthy Opportunities Pilot. In this first-of-its-kind program, the state works with health plans to use Medicaid dollars to pay for non-medical items or services that can prevent sickness. These could include medically tailored meals for a diabetic patient, assistance in paying first month’s rent, or transportation to doctor’s appointments.

This pilot, by using healthcare dollars to directly address social drivers of health, signals the state’s commitment to addressing health inequities. It has also amplified existing health-equity dialogues throughout the state, particularly when it comes to measuring health outcomes.

The Role of Measurement in Healthcare

The healthcare sector is driven by data, ratings, and metrics. For example, the Centers for Medicaid and Medicare Services uses a five-star rating system that measures the experiences that Medicaid enrollees have with their healthcare plans and providers. Metrics include how easy it is for patients to schedule an appointment or quickly receive care. Star ratings are published on the centers’ website for anyone to see. They also impact payments received by health plans and providers.

A healthcare-equity index also provides a snapshot of key healthcare statistics across the state. Both patients and healthcare institutions can use this information to identify problem areas. In North Carolina, the coalition will undertake a collaborative process to decide which measures are included in the index. Early conversations have pointed to data that looks at the social drivers of health mentioned above—food and housing insecurity, which are major causes of poor health outcomes. Coalition members are also interested in measuring maternal health, chronic care management, access to behavioral care, patient experience, and healthcare affordability, amongst other elements.

This information is not currently housed in one standardized place. Because healthcare is decentralized, data tends to exist in silos. Information about a particular community or issue may be available to the institution holding that data but not a broader set of partners working on health equity. A statewide effort to regularly collect health data helps create a more comprehensive picture of health not just for providers, but ideally for community organizations and patients as well.

Putting an Index to Work

While measuring health inequities is an important component of equity work, numbers alone won’t move the needle on reducing those inequities. As the work of developing this index gets underway, the following considerations are imperative:

How will the development of the index incorporate not just healthcare voices but a broad diversity of patient voices? Achieving health equity, as defined by the World Health Organization, requires looking at the “institutional processes [that] shape the distribution of power and resources.” This means that an index should consider equity not just in outcomes like care delivery but also processes like decision-making. Frequently, measurement tools exclude the perspectives of the very communities that they are seeking to “measure.” This can result in a mismatch between what aspects of health outcomes are flagged or invested in and what communities advocate for. Providing opportunities for those with lived experience of health inequities to share what metrics they feel are most crucial to understand is key to equitable evaluation.

How can the index be used to increase healthcare accountability? In the case of the CMS Star Ratings, healthcare institutions are compelled to deliver on their required metrics because of ratings’ impact on payment. In the case of North Carolina, it remains to be seen how a collaboratively developed index impacts peer accountability and transparency. Community stakeholders organizing around health equity will likely be interested in how the index can serve as a reflection/assessment tool for healthcare organizations themselves. What role are healthcare institutions themselves playing in perpetuating the inequities that surface in the index? How can the index be used by grassroots, nonprofit, and advocacy organizations to engage their healthcare partners on those dynamics?

The introduction of a healthcare-equity index in North Carolina is a helpful starting point to align efforts across the state. Greater data visibility could result in new approaches and better resource allocation. Actually improving health outcomes, however, requires more than just a shared set of statistics. Community perspectives on what gets measured and how are vital to ensuring that the tool’s design and application are themselves equitable. Those perspectives can ensure that the index evolves beyond a static dashboard and into an accountability mechanism.