As part of our In Conversation storytelling series, we speak with thought leaders, change-makers, and advocates who make up our community. We kick off this series with Dr. Joshua Liao, host of the Health Equity Conversations podcast, where he gives a platform to the people and groups working to improve equity and health through systems change.
Dr. Liao is an internal medicine physician at the University of Washington (UW), Associate Chair for Health Systems in the Department of Medicine and faculty in the schools of School of Medicine and Public Health, and an Adjunct Senior Fellow at the Leonard Davis Institute of Health Economics in the Wharton School at the University of Pennsylvania. Dr. Liao has committed his career to improving health care payment and delivery, and advises state Medicaid programs on a variety of payment and delivery issues.
Dr. Liao has published over 300 articles and 180 in peer-reviewed medical journals, including The New England Journal of Medicine, the Lancet, The Journal of the American Medical Association, and Health Affairs. In addition, his commentary has appeared in the Washington Post, Forbes, STAT, the Boston Globe, NPR, Harvard Business Review, and the Seattle Times.
Why did you feel that now is the right time to broach the topic of payment and health equity via your podcast, Health Equity Conversations?
In the US, policymakers and payers have spent the last decade using what are widely called “value-based” arrangements to reform payment and improve healthcare outcomes. I believe in the importance of using new payment methods – which fundamentally try to encourage clinicians and organizations to improve quality and cost-efficiency of care – to improve care. But a decade of reforming payment has also done little to address health inequities facing historically marginalized communities. If anything, there are reasons to worry that payment reforms could entrench or exacerbate inequity.
As the US health care community now turns toward the next decade of value-based payment, it has an opportunity to build on prior experience by fashioning payment into a tool for improving equity, not just improving overall outcomes. This felt like an important moment for launching Health Equity Conversations, which seeks to highlight groups working on these issues.
The idea of health equity must feel so vast and overwhelming. If you had to choose one thing that we (as an industry) could do to make a difference – a dent – what would it/they be?
I believe that whether explicit or not, intention precedes implementation. So while it may seem abstract, the first thing is to set an explicit intention to combat inequity via payment and care delivery reforms rather than focus on overall outcomes and allow inequity to emerge as an “unintended” consequence.
The quality improvement movement helps illuminate the potential benefit of intention-setting. Landmark publications dating back several decades suggested major quality deficiencies in the US health care system, prompting clinicians, organizations, professional societies, public agencies, and others to come together and create metrics, set targets, implement initiatives to drive progress toward those targets, and link quality performance to financial incentives.
Of course, the quality improvement movement hasn’t been without difficulties; there have been missteps and challenges. I also don’t mean to suggest that we can or should follow that same or similar approach for driving equity through payment.
The point of the comparison is that though quality is a vast and potentially overwhelming idea, an explicit intention to increase quality was a critical ingredient for the widespread quality improvement implementation that followed. I believe that an intention to eradicate inequity can and should power the implementation we need.
Your podcast guests have included policy experts, payers, and providers. What did you take away from hearing these different perspectives?
Through Health Equity Conversations, I’ve been honored to speak with individuals representing different roles in the health care system. It’s not hyperbole to say that whether in agreement, disagreement, or uncertainty, I have learned from each and every person.
That has, in fact, been my takeaway thus far – that there are, and should be, many different perspectives on an issue as fundamental as equity and how to promote it via systems change. This diversity of perspectives is important for at least two reasons. First, to reflect that many people and groups playing different roles must come together to achieve improvement toward the goal of equity. Second, to acknowledge that progress does not require the otherwise paralyzing requirement of universal agreement or consensus.
After a year of conversations, are you hopeful for the future?
I am. Systems change certainly requires pragmatism, content knowledge, and technical solutions. But we also need to remain anchored to the why behind the what – the meaning driving different people and groups to address equity. My goal with this series has been to provide both parts to help energize and direct future efforts.