Through Health Equity Conversations, Joshua Liao hosts a series of discussions featuring people and groups around the country working to improve equity and health through systems change.
In this installment, Dr. Liao spoke with George Abraham, MD, MPH, MACP, the President of the American College of Physicians (ACP), and Shari Erickson, the Chief Advocacy Officer and Senior Vice President of Governmental Affairs and Public Policy (Interim, at the time of the conversation) for the ACP.
This interview is a condensed version of the conversation between Dr. Liao, Dr. Abraham and Ms. Erickson, and has been edited for clarity and length. For full-length discussion, please access the audio recording.
Joshua Liao: Dr. George Abraham and Shari Erickson, thanks so much for joining us today. Would you start by telling us about the journey that led to your career path, and positions within the American College of Physicians (ACP)?
George Abraham: I’m an internist and infectious disease physician. I did medical school and initial residency training in India before moving to Singapore for additional training in infectious disease. I worked at the WHO (World Health Organization) in their HIV program in Uganda and Kenya, and then immigrated to the United States. I am a professor of medicine at the University of Massachusetts Medical School here in Worcester, Massachusetts. My interest in health equity and disparities started right from my training in India. After my residency training, I worked with the Missionaries of Charity which at that time was headed by Mother Theresa, now Saint Theresa. I was so impressed by the work they did among the underserved. For three years, I worked with them as a physician taking care of people in their orphanages as well as when they were hospitalized at my teaching institution. I continued to study that during my time on the WHO in Uganda and Kenya. I got to see a lot of disparities during the height of the HIV epidemic, and then subsequently here in the U.S. I continue to volunteer in free clinics and continue to advocate for health equity, which has been a passion that has continued to burn.
Shari Erickson: My role involves overseeing the operations of our Washington DC office and managing our overall advocacy and policy initiatives related to congress, as well as federal regulatory agencies. Prior to ACP, I was a Senior Program Director with National Quality Forum where I was responsible for an array of projects around national strategy for health care quality measurement and reporting. Prior to that, I was at what is now called the National Academies of Sciences, Engineering, and Medicine, working on a variety of projects going back to crossing the quality chasm. My interest in health equity comes from all the way back in those roots. A lot of my work in ACP now is around payment models and implementation of alternative payment models to help improve quality of care – and not focused on any one population, but to ensure that the entire population of the U.S. receives the highest quality of care possible.
Dr. Liao: Your backgrounds highlight how equity is a fundamental issue that has many layers related to policy, and models and delivery of health care. Could you share a little bit about major ways in which the ACP is currently advocating for or working on health equity?
Dr. Abraham: The ACP is really committed to combatting racial disparities that affect both health and health care. For example, in April of 2021, we developed a policy paper looking at health and health care disparities published in the Annals of Internal Medicine where we proposed a comprehensive policy framework for mitigating social determinants of health that contribute to poorer health outcomes. In addition to this framework, we included high-level principles discussing how disparities are interconnected, and offering specific policy recommendations on those disparities.
Ms. Erickson: Early in 2020, we released our new vision for the U.S. health care system. In it, we envision a health system that ameliorates social factors that contribute to poor and inequitable health (social determinants); overcomes barriers to care for vulnerable and underserved populations; and ensures that no person is discriminated against based on characteristics of personal identity, including but certainly not limited to race, ethnicity, religion, gender or gender identity, sex or sexual orientation, or national origin. Another component to that new vision is that we should have a health care system where the financial incentives are aligned to achieve better patient outcomes, lower costs, and reduce inequities in health care.
Dr. Abraham: In addition, there are other things that were addressed including fostering optimal health care for all members of society, including creating payment models that were equitable both to physicians as well as to other caregivers in the community, increasing access to high value care, person focused coordinated care, using the coordination between agencies both social service agencies and public health to build up that infrastructure of developing better resources.
Dr. Liao: Can you speak to ways in which ACP has been advocating for ways that payment in particular affects inequity or how payment can be used to reduce it?
Dr. Abraham: ACP has long advocated addressing systemic changes, and the payment system has to be factored in to address comprehensive care. We’ve talked about comprehensive payment models, suggested alternative payment models using deliverables or measurement factors that would better reflect what happens in clinical practice. We have a payment advisory committee that continues to work with [the Centers for Medicare and Medicaid Services; CMS].
Ms. Erickson: We have more than one committee of members who are on the front lines advising us on their experiences to help us better provide messages, influence, and provide input into the policy process, whether that be on the congressional side or with agencies. We also do a lot of outreach to private payers to bring these issues of importance to be front of mind for them. We also do work with staff and members on the hill to ensure that they’re fully aware of these issues so that they take these things into account, either in their oversight role of the agencies or in new legislation potentially as needed.
Dr. Liao: With that context, what are the two or three things that – if they were to be changed – would be the most meaningful in terms of advancing equity through payment?
Dr. Abraham: Prioritizing underserved populations by payers so that all payment models reflect the unique needs and challenges of an underserved population because conventionally payment models are so designed around the mainstream, larger populations of folks who have access to care that we often keep these people in the margins and in the shadows, when they really need them to be our priority and focus.
Ms. Erickson: We need the payers to prioritize, as Dr. Abraham said, inclusion of these underserved patient populations. As part of that, [payers] need to ensure that practices are rewarded for working with underserved populations, and those that are affected most by discrimination because of their race or ethnicity. Practices right now could be penalized because [payment models] aren’t able to adjust appropriately for inclusion of those populations. Another aspect of including [these populations] is really allowing [practices] to perform social drivers of health assessments, connect those patients with outside services; they need to know what those outside services are and where they’re available. With those type of rewards and incentives for the practices that really go directly to the patients as well, that’s a way that we can actually have underserved populations receive the long-term, high quality care that they should receive, as others do. Another aspect that I think we want to highlight is using a risk adjusted methodology that includes social drivers of health and comorbid conditions, and allows physicians to serve those patients without being penalized, as they are now, for negative outcomes that are out of their control. Physicians and practices that engage in these types of innovative efforts to really adjust appropriately and to take care of patient populations that need services, they shouldn’t be penalized. They should actually be rewarded for ensuring that these underprivileged populations have access to all the necessary care.
Dr. Liao: One of the things that stands out to me is that there’s a lot of learning to do. Is there a role for learning collaboratives or forums through which people can learn about how to do things like risk adjustment or create the right incentives, and if so, what might [these forums] focus on early on?
Dr. Abraham: I have to confess, I didn’t learn any of this in medical school. That’s why I’m probably still a novice, and I’m so grateful that you’re focusing on this, not only in your leadership in this area nationally, but also your leadership in the College in this area. This is something which should be fundamental to all of us.
Ms. Erickson: There are a couple of layers here when you’re speaking about learning. One is the understanding of the fact that disparities exist, and what that means. I think there’s a certainly a surface-level of understanding that. But really understanding in a more in-depth level, and also understanding one’s own role in that. The fact that there are implicit biases that are at play in any individual who is providing care or who is building these payment models, or who is building the data collection sources for these payment models – that implicit bias influences all of these moving parts. And that’s an area I know that I’m continually learning about for myself, as well as how it impacts many aspects of our health care system. And then there’s also another layer of learning where learning collaboratives would also be helpful, and that is how we build that into payment models. How those that are involved in payment models – from the physicians to their staff and other clinicians in the practices, even perhaps some of their patient population who may be interested in engaging this, as well as the payers – can communicate with each other about what they’re learning and doing. [Learning about] best practices so that what happens doesn’t just stay in one neighborhood, doesn’t get stuck there, so that we really can share those more broadly.
Dr. Liao: As a final question, what are a few takeaway messages for people who want to understand more about the ACP’s work in this area of payment and equity?
Dr. Abraham: The ACP is committed to combatting racial disparities that affect health and health care, whether it be in payment and delivery systems, or whether it be in fighting the prejudice at the root of the problem. The U.S. health care system must have some financial incentives that are aligned to achieve better patient outcomes, lower costs, and reduce inequities in health care. This will require greater investment in our nation's public health infrastructure, research, and public policy interventions. In all of those, the ACP is ready to be at the table working shoulder to shoulder with anyone else who is committed to achieving those goals.
Dr. Liao: Thank you for joining us today. More importantly thank you for the work that has become evident and clear that both of you are doing to combat inequities, and thank you for the ways in which you are doing that through the American College of Physicians. I’ve really enjoyed this conversation.
Dr. Abraham: Dr. Liao thank you for this opportunity and again thank you for your leadership in the college, and thank you for your leadership in this area nationally, and most importantly on behalf of Ms. Erickson and I thank you for the opportunity to have this meaningful conversation.