Achieving Equity in the Health System: The Commonwealth Fund's Vulnerable Populations Program

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Equity is a core goal of a high performance health system. However, in the United States, vulnerable populations, including low-income people, the uninsured, and disadvantaged racial and ethnic minorities, have more difficulty obtaining health care, receive worse care, and experience poorer health outcomes than other groups.

To ensure that these groups have access to health care capable of meeting their particular needs, The Commonwealth Fund has created the Vulnerable Populations Program, which includes both fellowship and grantmaking activities. The newly renamed Mongan Commonwealth Fund Fellowship Program (formerly The Commonwealth Fund/Harvard University Fellowship in Minority Health Policy) is designed for physicians interested in improving health care systems for vulnerable populations. The grantmaking program seeks to foster a health system capable of providing care that is patient-centered, population-based, comprehensive, high-quality, accountable, and integrated across the full continuum of care.

Identifying Models of Care 
A goal of the program is to promote the transformation of the safety-net delivery system into a high performance health system for vulnerable populations. Grants support work to identify delivery models that provide comprehensive, coordinated, and efficient care that meets the needs of vulnerable populations. Accountable care organizations (ACOs) are one such model, though there are concerns that ACOs may unintentionally exacerbate existing inequities in health and health care—for example, many safety net providers may not have the resources needed to participate. Under the direction of Valerie Lewis, Ph.D., for example, Commonwealth Fund–supported researchers at the Dartmouth Institute for Health Policy and Clinical Practice are assessing the implications of ACO formation for vulnerable populations, examining the extent to which ACOs are forming in vulnerable communities, and conducting a case study of a safety-net ACO to identify the unique issues safety-net providers face in the process of ACO formation and implementation. This work will inform policy options that maximize the benefits and minimize the risks of ACO formation for vulnerable populations.

Ensuring Sustainability
Another goal is to ensure that safety-net systems are financed in sustainable ways that bolster their capacity to provide high-performance health care. Several provisions in the Affordable Care Act—including the expansion of Medicaid and the reduction of disproportionate share hospital (DSH) payments that help cover the costs of uncompensated care—will alter traditional revenue streams for safety-net hospitals. It will be critical to develop funding mechanisms that sustain the operations of safety-net facilities in a post-reform environment. Under the direction of Deborah Bachrach, J.D., Manatt Health Solutions is analyzing current revenue streams of safety-net hospitals and how they are expected to change under health reform. These Commonwealth Fund–supported researchers are exploring funding models that promote the financial strength of safety-net hospitals and encourage the delivery of high-quality, accountable care.

Promoting Innovation in the Health System
Although the safety net is a central component of health care delivery systems serving vulnerable populations, it is also essential to support delivery system improvements in the broader health care system to meet the needs of all vulnerable groups, wherever they choose to receive care. Under the Affordable Care Act, Medicaid will cover an additional 16 million Americans by 2021, significantly expanding the program's reach and elevating its role in transforming health care delivery systems for vulnerable populations. Medicaid managed care programs offer ripe ground for delivery system innovations that could reach a significant proportion of vulnerable populations both within and outside of the safety-net system. Under the direction of Sharon Silow-Carroll, M.B.A., M.S.W, Health Management Associates, Inc., will identify ways in which Medicaid managed care can act as a lever to improve health care delivery to vulnerable populations—for example by showcasing state Medicaid agencies' innovative contracting approaches with managed care organizations, and by profiling Medicaid managed care organizations that are pioneering improvements in care delivery.

Training Physicians
Achieving high performance health systems for vulnerable populations requires well-trained, dedicated physicians who are capable of leading the transformation of health care delivery systems. Since 1996, The Commonwealth Fund has supported a fellowship program based at Harvard University that has developed physician leaders who are addressing the health needs of vulnerable populations. This year, The Commonwealth Fund renamed this fellowship program, formerly The Commonwealth Fund/Harvard University Fellowship in Minority Health Policy, to the Mongan Commonwealth Fund Fellowship Program, in memory of James J. Mongan, M.D., an innovative leader in health care delivery who had a strong commitment to improving health care for vulnerable populations. Dr. Mongan was a member of The Commonwealth Fund's board of directors and chairman of its Commission on a High Performance Health System.

The fellowship program is designed to prepare physicians for leadership roles in transforming health care delivery systems and promoting health policies and practices that improve access to high performance health care for racial and ethnic minorities, economically disadvantaged groups, and other vulnerable populations.

Based at Harvard Medical School under the direction of Joan Reede, M.D., M.P.H., M.S., M.B.A., dean for diversity and community partnership, the Mongan Commonwealth Fund Fellowship Program offers intensive study in health policy, public health, and management. Fellows complete academic work leading to a master of public health degree at the Harvard School of Public Health or a master of public administration degree at the Harvard Kennedy School of Government. Fellows also participate in leadership forums and seminars with nationally recognized leaders in health care delivery systems, minority health, and public policy.

Beginning with the July 2012 matriculating class, the fellowship program will be expanded to include an optional second year of practicum experience to supplement the fellows' academic and leadership development training. Fellows chosen for the second-year practicum will spend one year in a health care delivery system, federal or state agency, or policy-oriented institution. The practicum will be a competitive program open to first-year fellows, with a variable number of placements available each year. It will assist fellows in developing careers in delivery system leadership and health policy and will propel them on a trajectory to lead the transformation of health care delivery systems for vulnerable populations.

Both the Mongan Commonwealth Fund Fellowship Program and the grantmaking activities in the Program on Vulnerable Populations will help achieve The Commonwealth Fund's vision of creating a high performance health system for all by equipping health care providers with the capacity to meet the needs of low-income, uninsured, and racial and ethnic minority groups.

To apply for a grant from The Commonwealth Fund's Vulnerable Populations program, visit Applicant and Grantee Resources.

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