Structural racism and poverty correlate with a higher incidence of obesity among African Americans (49%). Social drivers of health, which affect a disproportionate number of nonwhite Americans living below the poverty line, account for up to 90% of people's health outcomes.

These are just two examples of data that highlight the need for fairness.

Health plans are well aware that it is possible to change this dynamic and improve clinical outcomes through better and more personalized member engagement. But overall, the health care system is not properly configured to engage the people who need help the most, including the 133 million Americans living with at least one preventable chronic disease. Most health care interventions designed to motivate or engage members to improve their health do not match members' day-to-day needs.

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In other words, most health system interventions lack equity.

Equity from a Health Care Lens

One of the best ways to understand equity and how it differs from equality is to look at the Robert Wood Johnson Foundation's 2017 graph of people who cycle.

In the first image, people of different physique (a disabled woman, a child, a tall man and an adult woman) attempt to ride the same type of bicycle with varying degrees of success. In the second image, the same people ride different bikes suited to their individual physique. The second image shows that everyone can travel with ease because everyone has a solution adapted to their needs.

When we consider these principles of fairness, it is clear why our institutions are failing so many Americans. By providing "equal" (same) care to everyone, we are not accommodating people with a higher (or different) level of need.

To provide care equitably, health plans must think critically about what will motivate high-risk and underserved people to participate, and avoid applying the same solution to different cohorts of members.

For example, non-white Americans consume less alcohol than their white counterparts, but experience higher levels of negative consequences due to higher levels of poverty, unfair medical treatment, and racial/ethnic stigma. Healthcare organizations that want to address alcohol consumption to improve health outcomes need to think critically about what would motivate those most at risk to reduce their alcohol consumption.

Too often payers and employers offer incentive programs that don't support behavior change, such as smoking cessation programs that offer rewards like a free t-shirt for reaching a goal, but few offer the opportunity to consult. a program administrator to celebrate progress.

A program with a simple goal and a rewards structure might work for people who are ready to make a change (and have access to nutritious food, time and 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 provided at the right time, developed with equity as a central goal, can drive change.

A recent study of Arizona Medicaid plan members with severe mental illness compounded by other co-occurring conditions illustrates this. For the 2021 study, Arizona's plan aimed to reduce hospital emergency department use through a program in which patients checked in daily with a mobile app. As long as they completed the 12-month program, participants were eligible to receive up to $250 in cash rewards that they could use for groceries, transportation and other essentials.

Members checked in daily, using the app to log completion of basic daily and weekly health-related tasks, such as eating healthy meals, checking blood sugar and blood pressure, and taking prescribed medications. weather. Every day, they received reminders and praise for their positive behavior, such as posting a photo of a healthy meal or entering a numerical value.

At the end of the 12-month study, medication adherence improved by 43% among participants and inpatient use decreased by 69%. The plan also saw a net promoter score.