Abt Conversations: Health & Equity - Massachusetts

All people are entitled to good health and safe environments. Increasingly federal, state, and local partners are seeking ways to improve health access and outcomes for everyone, no matter where they live, who they are, or how much they earn. In this podcast miniseries, Abt staff sit down with health leaders from Massachusetts, Minnesota, and the Pueblo de San Ildefonso to discuss their ideas on health equity, including challenges, innovative approaches, and next steps for their respective programs and communities. In this episode, Abt's Kaitlin Sheedy talks to MassHealth’s Gary Sing.

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Kaitlin Sheedy:  Hello, my name is Kaitlin Sheedy. I'm a senior associate at Abt Associates, and I'm joined today by Gary Sing, the director of delivery system investment in social services integration at MassHealth to talk about health equity in Massachusetts. Thank you so much for joining me today, Gary.

Gary Sing: It's a pleasure to speak with you.

Kaitlin:I know from our time working together that promoting health equity, especially among historically underserved populations, is a core goal for MassHealth. What does health equity look like to you and how do you know when you're making progress?

Gary: Yeah, it's a great question and it's something that's been top of mind for us for a while now. The most straightforward answer here is that we'll monitor the data that we're collecting while, at the same time, working to improve our data collection capabilities. And if we see a reduction in disparities, then we'll know that we're making progress.

But it goes beyond that approach. For example, we know from the literature that there are specific areas or populations where disparities are often observed, even if we at MassHealth have challenges in seeing those disparities in their full view because of incomplete data collection. But we don't want to wait until our data become perfect before starting to act, and so, we'll know we're making progress when we're already implementing policy changes or requesting authority from CMS to do so. So a couple of things just come to mind here.

One thing that we've done that we have already kicked off is we're providing housing supports and nutrition supports to certain ACO members through our flexible services program. And we know that, so often, there are disparities in the kind of folks who have these health-related social needs when compared to a white reference population, as an example.

And then, in terms of that bucket of things of where we're requesting authority from CMS to make some policy changes, well, as part of our next 1115 waiver proposal, we're requesting authority to try to improve or to reduce some of the disparities for the maternal health population. So we want to extend postpartum eligibility to 12 months. And, really, the thinking behind this is we know that maternal morbidity and mortality rates between black and white women is different, right? And if we can extend that eligibility to 12 months, there will be greater health coverage, which will hopefully help to reduce some of those disparities.

And then, one other population that we are focusing on in our next waiver is the justice-involved population. And we want to implement 12-month continuous eligibility for justice-involved individuals upon release from incarceration. And we know that Bblack and brown folks are disproportionately represented in the justice-involved population. And because there is such a stark disparity in health outcomes for those individuals, having this 12-month continuous eligibility can help to reduce some of that churn that often happens with people losing their Medicaid eligibility because of paperwork issues as an example.

The final thing that comes to mind regarding the question of how we'll know we're making progress is when we're having focus discussions about health equity and reducing disparities with our contracted partners. Like, as an example, our ACOs and our hospitals. It's not just enough for us at MassHealth to be thinking about health equity. There has to be an aligned focus throughout the delivery system. And as those conversations ramp up and continue, we're hopeful that we'll be able to make meaningful progress collectively as a community.

Kaitlin: That's great. So, you’re using your own data, data from the literature to inform next steps and continuing to have these conversations with folks at all levels about health equity to propel you forward. What are some key strategies MassHealth is pursuing to further health equity and reduce disparities in its Medicaid program?

Gary: Yeah, so I've already mentioned a couple of strategies. And so I'll focus in on that last point that I made, which is about having focused discussions about health equity with our contracted partners. So a key driver of those discussions is going to be an initiative that we've included in our recently released 1115 waiver extension proposal, which is that we want to tie significant financial accountability for our ACOs and our ACO-participating hospitals to not just report on health and healthcare disparities, but to actually reduce those disparities. And we believe that putting meaningful dollars behind this effort will further raise the level of focus and attention on health equity significantly, and help keep it a shared top priority for us and our ACOs and our hospital partners.

One other strategy, which we're carefully thinking about right now, is how best can we engage with and hear from our members and the community. We know that the policies and the programs that we implement can only be strengthened and improved with direct feedback and suggestions from those that are being impacted.

Kaitlin:  We at Abt have had the opportunity to work closely with you all at MassHealth over the last several years to provide technical assistance and support, peer learning for the accountable care organizations, and community partners in the Commonwealth's Medicaid 1115 waiver. How does this collaboration support MassHealth's equity strategy and further your goals?

Gary: Yeah. So to provide some brief context for those who may not know, you mentioned the accountable care organizations and the community partners. So the community partners are a companion program that we launched alongside the ACO program, where we procured community-based organizations to provide care coordination supports for folks with certain behavioral health and long-term care needs. And so, as you mentioned, you all worked really closely or have been working closely with us to provide technical assistance to not just the ACOs, but also to the CPs. And given that we know that health disparities generally are experienced by folks with behavioral health and LTSS needs compared to folks without BH or LTSS needs, we view anything that we can do to strengthen that part of the delivery system as work that is aligned with our equity strategy.

And going a little bit deeper from there, I can give a couple of examples of health-equity focused TA that our ACOs and CPs have received. So, for example, we have a community health center that's participating in an ACO that receives support in formally weaving a clinical equity lens through every aspect of their care model. And they're now looking at disparities in health outcomes, access, and other measures for members. Another example, one of the community partners used the TA support to provide a beginner language and culture course that serves as an introduction to Spanish for frontline workers who interact with members recovering from different types of addictions. And there's an ACO that is receiving training in consultative TA to better support members with housing needs on top of their medical and behavioral health needs. So Abt has helped many of our ACOs and CPs, I like to say, level up their health equity competencies and capabilities, which we're really excited about.

Kaitlin: Yeah, it has been really exciting to see an increased focus in technical assistance projects on health equity, that ACOs and CPs are really focused on addressing this important issue. What have been your most difficult challenges or surprising lessons in MassHealth's work to promote health equity?

Gary: Yeah, it's sort of hard to choose what's been the most difficult challenge, because there's been so many challenges, but I think one of the trickiest items, and it may not be as flashy as some folks might imagine, but is thinking through how do we improve our collection of race, ethnicity, language, disability status, gender, sexual orientation, and gender identity data? It can be challenging deciding which standards to use since there are numerous standards out there. And the federal government itself has several standards that are in use. On top of that, many of the IT systems that we use to intake and store the social risk factor data were designed with specific program reporting requirements in mind, or they're tied to other systems. And so, making changes to the specifications of these systems has substantial ripple effects. And it's not an easy one quick fix to fix everything.

So we're having conversations with the right folks, but it's definitely been tricky and I'm sure many other organizations are finding themselves in similar situations. And on a related note, we're also thinking through situations when members don't want to disclose their social risk factor information. Because, for example, they may be worried about how the provider, or the health plan, or we as the state are going to use that information. This is an understandable concern that ideally the folks that are collecting the information, they would be trained to know how to respond to these sorts of concerns. But recognizing that there's real work to be done here, to go into training staff and to educating members about why collecting this information is so important.

Kaitlin: Thank you so much, Gary. It's always a pleasure to speak with you, and we're looking forward to seeing all of the exciting initiatives Massachusetts has ahead in the coming years.

Gary: Great. Yeah. Thank you for giving me a chance to share about all the cool work that we're doing here in Massachusetts.