In this episode, Josh spoke with Lisa Simpson MB, BCh, MPH, FAAP, the President and CEO of AcademyHealth.
Joshua Liao: Lisa Simpson, thank you so much for joining us for Health Equity Conversations. Before we jump in, could you tell everyone a little bit about your personal journey and path to AcademyHealth?
Lisa Simpson: Like you and several others who worry about health care, I come from a clinical background. I am a pediatrician by training and drawn to the question of “why are my patients experiencing these outcomes?” I did my pediatric residency in Hawaii so I had a very diverse patient population, race ethnicity and socio-economic status. Early on I started asking those questions about disease patterns not knowing I was really seeing SDOH of health even back then in the 80s.
So that drew me to it, and from there I went into Public Health and health services research because I am a true believer in having the data and the evidence to inform what changes we make. We do that in clinical care; we believe in evidence-based practice. Why any less of policy makers or folks in health plans and other large systems who make choices that drive the health outcomes of millions of individuals and communities?
JL: I followed with interest a particular [Academy Health] initiative called Payment Reform for Population Health a number of years ago. My understanding about that was it was a collection of activities: collaboration, literature assessments, stakeholder interviews, a body of work to try to drive it inside about how do we connect health care payment to community wide population health. Can you share a little bit about that experience and major learnings from it?
LS: You’ve described some of the components very well. It’s sort of in our DNA at AcademyHealth that we recognize that these are systems problems, and so you need to bring multiple parts of the systems together to consider potential solutions. At the same time, you need to bring non-systems thinkers, folks outside of those who created the problem, so to speak, to be disruptive and think differently.
There were many of the usual suspects sitting around this multi-stakeholder guiding council that we had. But we also had some not so usual suspects, like representatives from community-based organizations and social services organizations, the CFOs within health care organizations, to really try to grapple with the on the ground challenge of rethinking of how payment happens.
I think importantly [this work] really emphasized that the payment component of payment reform is – as complicated as it is – only one part of the solution. At the same time that you alter your payment streams, you have to have a different set of organizations to then achieve that equitable population health outcome that you are seeking. One of the things that it made very clear was that we often talk about medical and public health but bring in social services, social sectors, because you’re talking about housing, transportation, nutrition, WIC providers, etc. Often what is needed to bring those conversations forward is that trusted convener.
I think one of the other things I’ve learned in my journey from working in clinical practice, then state public health and federal policy, and now in an association is that one size does not fit all. So, when we talk about national policies and these big themes of payment reform, it’s not all going to work the same in every community. I think we have to get much more nuanced in our understanding of the match between community needs, community capacity, community assets, and the payment streams.
JL: I hear two main things here: that payment is an important motivator and driver of behavior but it is not the only one; and that really the delivery model, and community capacity, and infrastructure have to be there. Could you tell us a little bit about if people say, we have the models inflight, we’re working on data streams, we’re trying to get the right people at the table, but how do we build that environment where people feel like this is safe to go to places where we have not gone historically?
LS: It is a fundamental opportunity for health care transformation, to start focusing on the trust infrastructure. Not just all the tools and incentives that we layer on that because we need that trust infrastructure. That’s one of the reasons AcademyHealth is actually working with the American Board of Internal Medicine Foundation on their trust initiative to try to build a research agenda around not just what drives trust but importantly on how do you build it.
It sounds somewhat perhaps glib but I think change happens at the speed of trust. So, if organizations are not trusting each other, if individuals cannot trust in the organizations, long lasting sustained change will not be possible. Because we’re humans, change is hard, and we have a very strong status quo bias. I think that there are models out there and communities out there who have really invested in that community capacity for trust, and where it has been broken, are working on rebuilding trust. Each community is at a different stage of that trust relationship.
JL: I want to key in on that idea of intention. As you may know that’s actually one of the principles of the work that my colleagues and I are trying to work on and how to contribute on this area of equity and payment and related delivery systems. Our thought is that intention must precede implementation and even if you don’t do this in an explicit way, it happens anyway – you encode implicit intentions.
We’ve been edified by organizations thinking about that. It shows up in strategic plans, in mission statements, in sprints for the year. Tell me a little bit about how AcademyHealth is thinking about equity in your strategic plan, and otherwise, going forward?
LS: This is essential. Yes, we have focused on equity and we used to call it disparities, just less than a decade ago. So, the Disparities Interest Group was founded at AcademyHealth in 2006. In 2015, we stepped back and realized that for us to address diversity and inclusion, especially in health services research, we needed to do more. So we established the Center for Diversity, Inclusion and Minority Engagement as an investment out of our organizational reserves by our Board, so we established that center.
And still 4 years later, we realized that was not enough. The events of 2020 and the killing of George Floyd, and so many other African Americans, coupled with the disparate outcomes from the pandemic, just made it absolutely clear that even though our world, our mission is focused on health services research and bringing evidence to bear on policy and practice, we have to do more. Our field and our organization had to step up, and so we very intentionally developed our framework for addressing this, which is unique to AcademyHealth, in that it addresses what we can do as an organization, what we do with our members and partners, and through influence through thought leadership and advocacy – because we can use all of these tools to try to drive this change.
We cannot innovate our science without addressing equity and inclusion. We can’t achieve equity and inclusion without changing how we do research. While it doesn’t solve the larger equity challenge of health care, if we can really start helping our field do an even better job of addressing the data and evidence needs that then allow us to learn from healthcare transformation efforts so that we can accelerate equity, that’s an achievement that I would be proud of.
JL: Let’s talk a little bit about health services research, I think few would argue that promoting equity should involve translating evidence into policy and practice. Essentially, what you’ve really eloquently described here. I personally certainly believe that’s the case and particularly in the area of payment inequity, we need that. But in my opinion one of the challenges we have is that we still lack some of those foundational pieces, in my opinion a research agenda or perhaps a research community, to get from where we are to where we want to be in translating evidence into action. How are you thinking about this?
LS: I’m so glad you’ve highlighted that need. I agree on part one but not so much on part two. The research agenda, absolutely. We have not taken the time to step back and link two key concepts that existed in the initial IOM Framework for Quality and where we are today. We’ve talked a lot over the years in the payment world, about value, low value care, and high value care, and incentivizing value. And those conversations have historically been devoid of mention of equity, and hence why your work that you’re doing is so important. At the same time the work of equity has been, for decades, and it’s nuanced and rich, and it has been ongoing, but again the conversation around value in care has not come together. Now, those are two very rich bodies of evidence, but yet they’re separate.
One thing that we are doing which is daunting, as well as very exciting, is thanks to support from the Donaghue Foundation we have launched a new initiative focused on high value equitable care, to come up with specifically a research agenda to focus future investments for research funders on what we need to know to actually understand how to drive high value, equitable care at the same time.
Because I think one of the points that you make in your statement of principles is that for too long we’ve talked about equity or thought of it as an unintended consequence, and so disparities is just what happens when you don’t do it right. Well, no, that’s not the case. It’s almost designed in because of our history in this country. And so, we have to design in equity from the start.
This is a very exciting body of work that we’re doing over the next two years, and it will culminate with an in person convening to develop the agenda which we will then broadly disseminate. The question to get to implementation is: ‘can we recruit the funders to listen?’ Because like all other aspects of incentives and payment incentives, researchers will do research in those areas that they can get support for. We also have to align research funders to that research agenda.
You said we also need a research community. I think we already have one. AcademyHealth is the home for those who care about both value and equity. I mentioned those interest groups, if there's more we can do to convene this group to nurture those who are committed to those two things at the same time, we welcome your thoughts. This is absolutely what AcademyHealth wants to do.
JL: I am looking forward to the findings from [high value equitable care] initiative; count me as an interested party. With respect to the [point about research communities], I’ll say there has been rich evidence in value and in payment, and also in equity, and [the need and opportunity in] bringing them together is at the heart of my comment.
As a last question: is there anything else that we haven’t talked about yet, but that you feel that we as a health care community, and perhaps those of us in health services research, should really prioritize right now to meaningfully advance equity through payment, delivery, and related initiatives?
LS: There are two areas that I think need focused investment because of the opportunity. The first is focus on payment transformation for equity in Medicaid programs. As a pediatrician taking are of kids who disproportionally rely on Medicaid financing, where the rubber meets the road is through state policy and programs. AcademyHealth works very closely with state policy makers through a number of different state networks. I think there’s even more opportunity to study the changes state policymakers make in their Medicaid programs, and the managed care plans that they partner with, to see what does work for improving equity.
The second area is monitoring what will happen with the new CMMI initiative, ACO REACH, to drive equity. I think that is a tremendous opportunity. At the same time, I really hope my colleagues at CMMI are really investing the resources necessary to properly evaluate the models that are supported. And not to say, this did or did not work. But to say, how did it work, for which subgroups of the population, under which conditions in which communities. It’s that disentangling the complex reasons why implementation works differently in different context – that’s the kind of evidence and data we need to then take those elements that were successful at driving equity, and replicate those, and not do the things that don’t work.
JL: I will return to a thing you said, this is daunting but really important at the same time. Grappling with the intention and the values that we lead with, but also getting down into where the rubber meets the road (payment, delivery, and policy and practice implementation). We need lots of work from lots of angles, and I’m really glad to hear about ways in which you and AcademyHealth are doing that.
Thanks again for joining us today. I really enjoyed this conversation and look forward to sharing it with everybody who's listening.
LS: Great to talk with you, Josh. Thank you.