Photo Credit: Sasirin Pamai

The success of inclusive value-based care is essential to improving population health disparities and health outcomes for the LGBTQ community.

The growth of value-based care has not yet eliminated many healthcare disparities for various populations, especially those at higher risk of health issues. At the same time, there has been a relative lack of models, programs, and plans to remedy such disparities in at-risk populations. LGBTQ patients are often at higher risk for a variety of medical issues and are also affected by some common health themes unique or unusual to the queer context. However, few, if any, value-based programs take the unique needs of LGBTQ populations into account. Initial efforts, like more standardized data collection of sexual orientation and gender identity information, which itself comes with attendant concerns like privacy, are an essential prerequisite to bringing value-based care more fully in line with the interests of LGBTQ individuals. Moreover, queer-conscious, inclusive, value-based programs are essential to remedying persistent LGBTQ health disparities.

The Growth of Value-Based Care Has Not Conquered All Ills

Over the last several decades, the concept of value-based care has grown dramatically in importance. Simply put, value-based care attempts to control and reduce costs while maintaining and improving outcomes. Value-based care encompasses different forms but often ties payment to quality metrics for patient health outcomes. In some cases, if value-based partners can maintain certain quality outcome thresholds, payors may remit to that partner some fraction of the accrued “shared savings” as an incentive for practices and provider groups to promote cost-effective means of obtaining high-quality health outcomes for their patients.

Just under a decade ago, in 2015, the Secretary of Health and Human Services publicly committed the Centers for Medicare and Medicaid Services (“CMS”) to tying at least 90% of traditional Medicare fee-for-service payments to health outcomes by 2018. Since then, the focus on “value-based transformation” has only increased dramatically. Value-based care has developed into a formidable healthcare landscape in its own right. During the COVID-19 pandemic, investment in value-based care companies increased almost fivefold.

However, the proliferation of value-based care has not done away with persistent “health disparities, uneven quality, and continued rise of health care costs, and the concomitant threat to federal and state budgets, (which) requires a renewed focus on spreading the adoption of advanced forms of alternative payment models.” These disparities persist for LGBTQ individuals as well, and many LGBTQ patients anticipate disparate or even insulting treatment, which secondarily affects patients, in some cases causing queer patients to self-censor or not seek treatment in the first place.

It is difficult to squarely find discussion a discussion of the intersection of queer healthcare and the legal facets of value-based care, but that discussion is essential to understanding how to build and sustain a value-based program that promotes queer health and—in a broader context—community health outcomes. Those goals are also key drivers of a value-based care program’s sustainability. In turn, for obvious reasons, value-based partners seeking to benefit from their value-based agreements need to understand how to design, negotiate, and operate within a value-based program to reap the benefits of their contracts—with the bonus of promoting better health outcomes for their patients. Yet, value-based care is essential to improving the disparities in LGBTQ health outcomes.

Why Inclusive Value-Based Models Are Essential

Perhaps not surprisingly, there has been a lack of focus on collecting queer healthcare data. This, in turn, places a significant impediment to consciously crafting an inclusive value-based program because data regarding LGBT status are not routinely collected or said slightly differently. Because value-based care generally ties payments to quality, the lack of reliable queer quality metrics is a serious problem for provider groups or plans trying to design an LGBTQ-inclusive value-based program. As explained by Dr. Nicole Rosendale, MD, associate professor of Neurology at the University of California San Francisco and co-director of UCSF Global Neurology and Neurologic Care Equity (BALANCE), “because sexual orientation and gender identity is not routinely collected in health systems, LGBTQ+ people are often invisible”.

However, issues of sexual orientation and gender identity data collection in electronic health records, which presents a broader concern than solely in relation to value-based care, is not an impossible one. Moreover, given the increasing reach of value-based care, the improvement of queer health outcomes is fundamentally tied to designing and implementing an inclusive value-based program.

Across the US, there is no question that LGBTQ populations often have negative experiences—particularly in the absence of affirming care—and may suffer from patterns of both common and relatively unique issues, which can prove to be a significant barrier to care. These patterns can and should be addressed at the group level when designing an inclusive value-based program. In New Jersey, for instance, a map of affirming care by Garden State Equality shows geographic gaps in care and arguably a shortage of providers overall. The high levels of disparate treatment experienced by LGBTQ patients is itself a barrier to improved outcomes and a serious population-wide concern for inclusive value-based care models.

What Types of Common-Sense Steps Can Practices Take?

Value-based care targeted to particular demographics, including LGBTQ individuals, is essential to incentivizing providers to encourage and help produce better queer health outcomes and are assisted in anticipating patterns of prevention and treatment needs, as well as reducing the costs of common services.

Removing implicit barriers like sensitivity training for practitioners and staff or even small symbols that suggest a welcoming environment can become cost-effective ways to promote patient engagement, retention, and quality. Appropriate physician-patient matching can also facilitate better outcomes and fewer data gaps that could skew and harm a partner’s results within a value-based program. Incentivizing providers to understand community-level considerations and to see and hear their patients in a manner that is not stigmatizing and off-putting is essential in producing better outcomes. However, as one study suggested, inclusive health plans can result in lower costs and better outcomes. Practices and providers can also take proactive steps, including plans and value-based programs that incentivize CMS to start requiring culturally competent care for various patients, including LGBTQ individuals. Even relatively costless steps like promoting an outwardly welcoming environment can have a pronounced impact on the quality of care and patient retention.

Another conclusion, clear in the aftermath of the COVID-19 Pandemic, is that those interested in promoting and harnessing the benefits of LGBTQ-inclusive value-based care should have a strong foundation for telehealth services. Telehealth services can help make up for the geographic disparities that may prevent members of the LGBTQ community, especially in certain isolated areas, from accessing care locally. This, in turn, requires careful contract design and compliance to ensure that all telehealth services are in accordance with respective state and federal laws.

Many disparities along race, gender, and sexual orientation and expression lines still exist, and active incentivization of more equitable care should be a necessary goal of value-based transformation. For instance, providers, programs, and plans should not underestimate the value of outreach to key stakeholders, like relevant community-based organizations, to reduce costs and improve outcomes. As monkeypox becomes more prevalent again, all stakeholders would do well to take heed of successes in response to the monkeypox outbreaks that occurred in 2022, when the North Jersey Community Research Initiative (“NJCRI”) in Newark, Hyacinth Foundation in Jersey City, in partnership with the city, provided vaccines primarily to members of New Jersey’s LGBTQ population, who were considered to be at higher risk.

Those actions likely created a worse epidemic, which could have had staggering attendant health and other costs. Moreover, accounting for foreseeable costs like the JYNNEOS smallpox vaccine, which is used prophylactically against monkeypox, or Pre-Exposure Prophylaxis (PrEP) HIV-prevention medication within agreements themselves, are crucial components of crafting a sustainable, inclusive, value-based care program. Plans, providers, and inclusive programs should consider accounting for these foreseeable cost categories rooted in knowledge of population health and the interests of the LGBTQ community. When designing and signing a value-based agreement, these considerations should occur at the contracting level.

Similarly, and to the extent prescription benefits are costs attributed to the provider, the value of rebates can be essential to the success of a Value-Based Program. For instance, emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamid, the two most popular versions of PrEP, have seen a progressive increase in list price but drops in the net price after factoring in Pharmacy Benefit Manager (PBM) rebates. As many or most value-based agreements do not account for rebates, those costs – at least concerning certain categories of patients – may be attributed at the “list price” rather than “net price”, with the effect of artificially inflating a provider group’s Total Medical Expense (TME), Total Cost of Care (TCC), or other price metrics. These types of considerations can even be do or die for full-risk groups. To be clear, these concerns permeate all value-based agreements because the reality is that any heterogeneous population of attributed members will include LGBTQ people.

Where the bloc of LGBTQ members is particularly large, employers may also be able to take certain additional steps to address these issues. For some larger employers with “a fairly large group of trans or even LGBTQ employees, some of the specific needs, and the conditions that are comfortable engaging with might be slightly different than the overall population, creating an exchange product that is specifically designed around the needs of the LGBTQ and trans community.” At the practice and provider group levels, knowledge of common issues facing the community—not just hot-button issues like HIV prevention and the prevention of other health concerns—but issues that can be highly susceptible to prevention and early treatment, like mental health and substance abuse issues, as well as concerns about being stigmatized by healthcare providers.

Also, at the practice or provider group level, transforming to value-based care often entails steep additional startup costs. For this reason, many participants in payors’ value-based programs are groups of provider practices, such as Accountable Care Organizations (ACOs), Managed Services Organizations (“MSOs”), or Independent Physician Associations (IPAs)—in part to effectively leverage the power of numbers when contracting and dealing with the payor. At a minimum, this type of transition requires strong knowledge of the legal, transactional, and regulatory environments when starting an ACO, MSO, or IPA. However, in my experience, it requires a strong legal partner if and when the time comes to negotiate with payors to effectuate contractual rights on various issues related to value-based agreements. I have previously written about New Jersey’s new PBM law, which takes effect on January 1, 2025, and which could render at least some rebates part of the price of a prescription drug – by law – in turn making it hard to argue that rebates should not reduce TME or TCC for fully-insured plans even where the value-based agreement does not expressly provide for rebates.

Finally, plan-level steps can be taken to support creating inclusive value-based programs. Plans can heed many of the same lessons discussed in brief above, aiming to develop more efficient, cost-effective systems that produce better health outcomes and, ultimately, reduce the risk across the plan’s population and the plan’s costs. Small steps—like SCAN Affirm, a Medicare Advantage plan targeted to older LGBTQ adults—have already been taken in that direction, yet as of early October 2024, only had about 1,000 members enrolled. As a rule, however, demographically-inclusive plans remain an uncommon feature of most value-based programs or agreements. And the populations that stand to benefit from those inclusive value-based programs, including LGBTQ individuals, are arguably those populations that need these programs the most.

Conclusions

As noted, plan design, best practices, compliance, and the wherewithal to push back when payors invariably seek to push back against sharing the benefits of positive value-based care outcomes are also essential to the complete success of inclusive value-based care programs. Conscious planning, careful review, and auditing are required to avoid fights with payors on cost inclusions and rebates. However, the success of inclusive value-based care is essential to improving population health disparities and health outcomes for patients from those communities. In a healthcare environment marked by recent drastic expansions in the scope and market share of value-based care, inclusive, queer-conscious value-based care models and programs are essential to bridging persistent LGBTQ health disparities.