Structural racism and poverty are correlated with a higher incidence of obesity among Black Americans (49%). Social drivers of health, which impact a disproportionate number of non-white Americans who live below the poverty line, account for as much as 90% of individuals’ health outcomes.
These are just two examples of data that highlight the need for equity.
Health plans are well-aware that shifting this dynamic and boosting clinical outcomes is possible through better, more personalized member engagement. But by and large, the healthcare system is not adequately set up to engage individuals who need the most help, including the 133 million Americans who live with at least one preventable chronic disease. Most healthcare interventions intended to motivate or engage members to improve their health don’t align with members’ day-to-day needs.
In other words, most health system interventions lack equitability.
Equitability Through a Healthcare Lens
One of the best ways to understand equitability and how it differs from equality is by looking at the 2017 Robert Wood Johnson Foundation graphic of individuals riding bicycles.
In the first picture, individuals of different physiques — a differently-abled woman, a child, a tall man and an adult woman — are all trying to ride the same type of bicycle with varying degrees of success. In the second image, the same individuals are riding different bicycles tailored to their individual physicality. The second image demonstrates that every individual can ride with ease because they each have a solution that is tailored to their needs.
If we consider these principles of equitability, it’s clear why our institutions are failing so many Americans. By offering “equal” (the same) care to everyone, we’re not accommodating individuals with a higher (or differing) level of needs.
To deliver care in an equitable way, health plans need to think critically about what will motivate high-risk, underserved individuals to engage – and avoid applying the same solution to different member cohorts.
For example, non-white Americans consume less alcohol than their white counterparts, but they experience higher levels of negative consequences from drinking because of higher poverty levels, unfair medical treatment and racial/ethnic stigma. Healthcare organizations that want to address alcohol use to improve health outcomes, should think critically about what would motivate higher-risk individuals to reduce alcohol consumption.
Too often payers and employers offer incentives programs that do not support habit change, such as smoking cessation programs that offer rewards like a free T-shirt for hitting a goal—but few offer opportunities to check in with a program administrator to celebrate progress.
A program with simple reward-goal structure might work for individuals who are ready to make a change (and who have access to nutritious food, time & access to exercise, etc). But for many, especially those with fewer resources, there is little external motivation at play.
Engagement in Practice
On the other hand, the right incentives delivered at the right time, developed with equitability as a core focus can drive change.
One recent study of Arizona Medicaid plan members with severe mental illness, compounded by other co-occurring conditions, illustrates this. For the 2021 study, the Arizona plan sought to reduce utilization of hospital emergency departments (ED) through a program that involved patients checking in daily with a mobile app. Provided they completed the 12-month program, participants were eligible for up to $250 in cash-based rewards they could put toward groceries, transportation costs and other essentials.
Members checked in every day, using the app to log the completion of basic daily and weekly health-related tasks — such as eating healthy meals, checking blood glucose and blood pressure, and taking prescribed medications on time. Every day they would receive reminders and praise for positive behavior, such as posting a photo of a healthy meal or logging in a numeric value.
By the end of the 12-month study, medication adherence improved by 43% among participants and in-patient hospital utilization declined by 69%. The plan also saw a +62 Net Promotor Score. The total cost of rewards cashed in (about $36,000) was far lower than that of hospitalization, and most member participants said that they hoped to continue daily check-ins after the study concluded.
By diversifying member outreach and taking extra steps to ensure equitability, health plans have the potential to make a more significant dent in population health. They have the potential to demonstrate that by meeting individuals at their level, they can raise the bar with not only engagement but also happiness and quality of life.
About Anne Davis
Anne Davis is the VP of Government Markets & Strategy at Wellth, a venture-backed digital health company that improves adherence in chronic disease populations. Anne brings more than 20 years of healthcare experience to the Wellth team where she leads strategy across Government Markets. For the last decade, Anne has been focused primarily on improving care & experience programs for managed Medicaid and Medicare Advantage beneficiaries. At Martin’s Point Health Care, Anne led the Health Management team of nurses and social workers conducting utilization review and care management. Anne has worked with vendors such as Cotiviti, Eliza, Health Dialog as well as with health plans, health improvement organizations and nonprofits as a quality and evaluation consultant.
