Health Equity Conversations
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 episode, Josh spoke with Chris DeMars, MPH, the Interim Director of the Delivery Systems Innovation Office and the Director of the Transformation Center at the Oregon Health Authority.
This interview is a condensed version of the conversation between Dr. Liao and Ms. DeMars, and has been edited for clarity and length. For full-length discussion, please access the audio recording (available episodes accessible via Apple Podcasts and Spotify).
Joshua Liao: Before we jump in, could you start and share a little bit about yourself and how you got to your current role at the Oregon Health Authority?
Chris DeMars: I’m currently the Deputy Director of the Delivery Systems Innovation Office as well as the Director of the Transformation Center at Oregon Health Authority. I’ve been here for about nine years.
Before that, I worked at a relatively small local foundation called the Northwest Health Foundation. I did a fair amount of health reform and grant making especially in the advocacy realm and partnered quite a bit with the state in that role. I was really excited about how Oregon’s health reform and the coordinated care
Chris DeMars, MPH
Director, Transformation Center
Oregon Health Authority
organizations were shaping up, and so was very curious to join OHA on the inside. I was at Northwest Health Foundation for about eight years. Before that, I worked for the federal government in an office called the Government Accountability Office for six years in Chicago. I did health reform assessment and research for Congress, and a few other jobs prior to that. I have a Master’s in Public Health in Policy and Administration from the University of Michigan School of Public Health.
JL: I know that you and others at the Oregon Health Authority have set a pretty bold organizational goal around health disparities in the next decade. Can you share with everybody what that goal is and how you decided on it?
CD: The Oregon Health Authority has established a 10-year goal that was launched in 2020, so right in line with the pandemic, to eliminate health inequities in the state of Oregon over the next decade.
That goal was identified through a pretty robust process that engaged a number of us, about 100 people in the agency’s leadership, that went through a process that I won’t go into detail on but that you can imagine. Part of that process was a fair amount of community engagement as to where the community wanted to see the Oregon Health Authority go in terms of this goal. The process that we went through as staff and the input that we got from the community, we tried to align those and realized that the staff was getting to minutia and details and really focusing in; whereas what we were hearing from community was we need to eliminate inequities in the state and that will promote health in so many ways.
We decided to be driven by community and that is really where the goal came from. We decided that while it’s very, very bold, it actually sets this north star under which all of our work is following right now. With the pandemic, it only enhanced the importance of this goal. So we’re really excited about it and a number of different strategies that are being put in place right now. At the end of the day, it is what drives the work at the OHA.
JL: I really love the focus on community because candidly I think that is something that can be said as lip service. I’m curious as you think about what you learned from listening to community and setting this, I would consider, very bold goal, what would you say as advice to other groups that want to use community to inform their goals, what are some do’s and don’ts?
CD: I think the most important, well you could characterize it as a do or don’t, is to not engage community once, get their input, and then not circle back. To say it as a positive, to have an ongoing feedback loop. We realize that we need to do that and we’re not doing that as well as we should and will be moving forward. We’re putting processes in place to do that. So, I’d say that’s number one: have it be an ongoing conversation, an ongoing feedback process.
The other is not to assume that one community conversation, or one community organization that you talk with, speaks for all. It’s really important to not just broadly say, “we heard this through this one meeting so that’s what we should do.” Through this process that I just talked about, there were a number of different community conversations, and I think we did a better job than we have done in the past of looking more comprehensively.
JL: It’s really important to center policy implementation in this idea of policy intention. In my sense, that’s what’s behind goals like the one you’ve described. How are you thinking about intention and translating that into implementation at the Oregon Health Authority Transformation Center?
CD: I would say that intention needs to come from the top and our leadership at the OHA. The goal of eliminating health inequities is driven by the leadership at the agency. And I think that is so closely aligned with intention. Our health system transformation efforts that well predate this goal, which launched in the early 90’s, I’d say in Oregon we’ve always been lucky to have leadership within the agency, the agency that predated the Oregon Health Authority but that still managed our health systems efforts, with our legislature even at the governor’s level. That aligned leadership intentionality is just incredibly important.
JL: Do you think that that’s something that is, similar to the idea of listening to communities and making sure that that’s plural, and that evolves over time, I’m asking you to look ahead 10 years here, but what are the things that you’re thinking would be really high priority to make sure that that intention is carried forward across that period of time.
CD: Well, this gets back to the question that you had asked previously around do’s and don’ts, and I think it’s what we hadn’t done previously and we’re going to start building in is this ongoing communication and feedback loop with community. I think that building that in in a very intentional way – the process piece – is so important.
And I’ll mention something you didn’t ask about but something to really keep in mind here, is that what we have found, is there can be, maybe what I would characterize as a tension or a disconnect between the expectations at the state level in terms of how quickly we do things, and the amount of time that we need to build in to hear from community in an ongoing fashion so that community can inform our policy work.
We’re finding that’s so important to build in and it takes more time, and it has become a culture shift that is really important; I’d say exciting. But there’s a change happening right now within the agency. I’m seeing it not just in OHA but in others that I’ve talked with in other states and other sectors, or other parts of the health system.
JL: Let's take that idea of intention and the goal that you have. Look forward into value-based payment (VBP) work that OHA is doing. Can you share anything about new models that are being either developed or discussed, or forthcoming?
CD: First, I’ll just say a little bit about what the Value-Based Payment Compact is. It is a voluntary compact that has been signed onto by all of our large payers and providers across the state to reach a series of goals around the percent of budgets that are spent on value-based payment and that increases over a five-year period. This came out of our Sustainable Health Care Cost Growth target, so it’s kind of based in cost but there’s also very much a quality and health equity component to this as well -- there are a number of principles that comprise the Compact and one of them that has many subcomponents is focused on health equity.
So, with regard to some of the models, we are at the preliminary stages. We’re really trying to focus on two models initially, one around primary care and one for hospitals. Within each of those, the intention is to design components that will ensure that health equity is promoted and health inequities are not exacerbated. And I’d say those are two different ways that value-based payment can be used. I’m happy to get into more detail on that if you’d like. I can’t give specifics [on these two models] now because we do not have them yet. But some of the ideas that have been discussed up to now are intentionally building in what, in Oregon, we call “traditional health workers,” those are community health workers, doulas, peer navigators, etc. – that body of the work force – and making sure those are worked into our VBP models, for example. Those [staff] would be to promote health equity. To ensure that inequities aren’t exacerbated, we want to make sure that there’s monitoring that is built in through specific measures within the VBP models.
And as you know, within value-based payment, the quality component is really what the definition of value-based payment is and making sure that you have measures in place within each of the models, we want to make sure that the measures, at least some of them, are used to ensure that inequities are not being exacerbated, and we’re actually addressing and promoting equity through these models. I hope that helps with some high-level examples at this point. Talk to me in a year and hopefully we’ll have these models more fleshed out, that will be voluntarily adopted and I’ll have more specifics at that time.
JL: You mentioned this idea of a compact and voluntary adoption, and what I’m hearing there, and what I know from my own experience, is that while financial incentives and money can be powerful motivations, they’re not the only ones.
Can you say a little bit about the non-financial elements of how you’re thinking about these payment and delivery models? How has that informed how you’re approaching the work that you’re doing and how could you see it showing up in the models in the future.
CD: You’re right that it is voluntary. The main incentive, if you will, or motivator for participating is the public reporting that we have built in – the monitoring that will be shared publicly on achieving these metrics. There’s a slew of different audiences that will receive the annual reports that will come out on the progress for the compact. I’d say that’s the main one. Also, though, I would say that there is pride and a commitment across our health system to move away from fee-for-service, toward value-based payment (VBP) and a healthy competition, almost, across our system.
So, I know that can be closely connected with public reporting, but even if we weren’t publicly reporting this in an intentional annual way, the movement that has been undertaken over the last number of years would be perhaps helpful to achieving these goals. Some of our health system payers are already beholden to some requirements around targets and value-based payment and these are for our Medicaid system. In Oregon, we have entities called Coordinated Care Organizations [CCOs] and they have built into their contracts’ requirements around VBP that are not as aggressive as we have it in the VBP compact. But they have been making movement, and every year, as part of the deliverable for CCOs, we have a conversation with them. It’s not just a written deliverable, but it’s a really nice way to get information from the CCOs about what they’re doing. They’re really excited and proud of the work they’re doing in this space.
Many of those CCOs also have a commercial line of business, so they were already starting to spread their VBP work before the compact was in place. That’s a long way of saying there’s momentum in the state and I think payers and providers see that this is the right direction to head, and know that it will improve care for their members and also for their providers, and allowing the providers to really address, holistically, the needs that their patients have (as opposed to what was allowed through fee-for-service). Those are some of the ways that I would say that, this being voluntary, I still feel hopeful that we will get to the goals over the next few years.
JL: As we look forward, what are the few things that you would say [to people who want to adopt something similar] – here are things you should start with and here are the couple of things you should be careful of as you start your journey?
CD: I already talked about culture shift with regard to promoting health equity and really engaging with community. Similarly, with value-based payment, it’s a culture shift and we found that education is incredibly important, and as part of the VBP compact, we have a work group that is identifying barriers to VBP implementation and then strategies to address those. One of the strategies is to come up with these models that I mentioned around primary care and hospitals that could be voluntarily adopted, and another is to come up with a VBP implementation toolkit, both for payers and for providers to really educate them on what we’re talking about.
As we all know, there are many different model types and it gets technical pretty quickly. Within Oregon where we have been with the Coordinated Care Organizations conducting a fair amount of technical assistance through my office at the Transformation Center, we plan to do that more broadly for the payers beyond the CCOs as well to help them achieve the target goals.
Another is that data is really, really important, and the sharing of data. Getting metrics data on a regular basis so the providers can make midstream adjustments – we’ve heard – is very important. Making sure that data by race and ethnicity are available so that metrics can be stratified so that inequities can be tracked. Data is key and there are lots of issues there, but certainly over the last few years we’ve seen improvements.
I would add that social risk adjustment and ensuring that providers that see a higher, disproportionate number of people that might have higher social-related needs, [making sure] that they are adequately reimbursed for providing the extra care and supports that are needed to ensure their patients or members receive supports to ensure that they are healthy, not just within the traditional medical care arena.
JL: To your point about certain historically marginalized or particularly vulnerable populations, there has been, in my view, a movement toward saying “how do we use area level measures to account for potential costs and utilization needs?”
Part of that is that it’s very hard to get that at the individual level. For example, in the ACO REACH Model that’s forthcoming with Medicare, they’re proposing some adjustment using ADI, the Area Deprivation Index. In Maryland there is the HEART Payment, Health Equity Advancement Resource and Transformation Payment, where the spirit is the same and again adjusted by ADI. What would you say are the pros / cons in your view of using area level measures versus individual measures?
CD: I would just say the more granular you can get, the better. I know that getting data on, for example, zip code, is not possible. If we’re looking at a county, some counties in Oregon are really big and it might have an urban core, and then it gets very rural. So, it’s hard to make VBP model design decisions based on data that is broadly applied. As granular as you can get would be ideal.
JL: Is there anything we haven’t talked about yet that you would like to mention from your perspective?
CD: In general, this is an exciting space where there are not as many answers as we would all like, but getting back to your initial question about the goal, I think we all know the goal. We want to use value-based payment to improve health. It is going to take us some time to ensure that the models are designed in such a way that that can happen. I think -- I don’t want to let perfect be the enemy of the good here -- we need to continue to move forward and we all recognize that the fee-for-service system is not promoting the kind of outcomes that we want to see.
I think it’s going to take all of us across the country to work together in our own spheres, share the information that we’re learning, and I have confidence that when we do talk again in a few years and look at the data that is coming out of these models, that we’ll be seeing movement. But sometimes when you’re in the minutia of it, it’s hard to see, so we’ll have to step back and reassess over time. So I feel hopeful about the future and I’m looking forward to working with others around the country on this journey.
JL: I want to thank you for the work that you’re doing in this space. For me, three major takeaways.
One is to set a goal that is not just anchored in communities, but that is bold enough that it shakes us. Two, to highlight that, that principle and those foundational pieces has to be tied to pretty technical things. Third, we are talking about payment and value-based payment, but there are all these other things, whether that’s community engagement, it’s building a culture in the community of health care provider organizations or payers, whether it’s competition or providing data feedback – there’s all these other things that we need to pair with the payment models to really make this work.
Thank you for highlighting that in your work and thanks for joining us today. We really appreciate it.
CD: Sure, thank you for having me.