NCQA: Accelerating Health Equity Outcomes

Brian Urban (00:22):
Yes, this is the Healthcare Rethink podcast. I am your host, Brian Urban, and today we have a really big treat on the show. We have Dr. Bryan Buckley coming from the NCQA. That is the National Committee for Quality Assurance, and he leads up the health equity team there. And man, we're so excited to have you today, Brian. We're going to learn just about how NCQA is pushing forward health equity across the ecosystem and of course, a lot about Dr. Buckley himself. So without further ado, Dr. Buckley, welcome to the show.

Dr. Bryan Buckley (00:59):
Good to be here.

Brian Urban (01:01):
Well, with any episode we have, we like to have our guests get to know our audience a little bit more and vice versa. So, wanted to understand a little bit more about Brian before the Doctor of Public Health from Harvard, of course. Going back to your early beginnings, what drove you to go into the space of health equity and take us to the journey of right now, how you got to be the Director of Health Equity at the NCQA?

Dr. Bryan Buckley (01:31):
That's a loaded question, man.

Brian Urban (01:32):
[inaudible 00:01:34].

Dr. Bryan Buckley (01:34):
Let's see. One thing to probably start off with my background, I guess the way I got into the sciences. So let's start all the way back to the origin story of Brian right now. So I actually started off in the microbiology space. So my undergrad was very much in the microbiology STEM field and I got blessed by having amazingly great professors that were like, "You know what, Brian? I think you could take this even further. We see a skillset of being able to really build bridges with other cross sector partners," and so that actually got me into the public health space. And this is important for you to know because this is how health equity gets intertwined. And so I started off my early career very much built in the public health space.
(02:26):
So even when I'm talking to people, I always remind people that I am a public health practitioner, first and foremost, and that is actually my way into health equity. So as we think about public health and really the population's health, health equity is critical to actually having a really healthy society because health equity is making sure that everyone does have that fair opportunity to be healthy. And so that is really this origin story of how I got involved in the health equity space. I never imagined I would take on a health equity job, to be perfectly honest with you, but it's one of those things that... You always hear that thing, "If no one, then who?" So I saw that my unique skills across public health and I'd had the opportunity to work in so many different areas of healthcare and health. As I said, I started off in the public health space, but I've worked for a hospital association, I've worked for a payer, I worked for a health plan and I've worked for a integrated healthcare system.
(03:31):
So in many ways, I feel like I have a linguistics skillset of being able to talk shop around public health, health equity in all of these different facets of healthcare. And so that's how I got to being Director of Health Equity. In my previous role, I was doing a lot of research around health disparities and community partnerships. But I could see... Often when I think about myself, I always think about, "What's the impact that I really want to make?" And NCQA seemed like a natural partnership to be able to take my lived experience, my experience both in the public health space and the healthcare space and marry it to many measurements and standards that really define what healthcare quality is in the ecosystem. And so that's how Brian Buckley became Director of Health Equity Initiatives at NCQA.

Brian Urban (04:23):
That's a great background. I love that you're a blend of many experiences that has now accumulated to a unique skillset so you can talk shop across the ecosystem. And that's really needed now more than ever in terms of collaboration between health plans, healthcare delivery organizations. I want to get a little bit deeper in the background of NCQA and what you're doing now because that was such a rich background and we'll probably go back and forth to your public health lens into your work these days.
(04:59):
But for our audience here, if you're not familiar with NCQA, and most all of our listeners are, but you began as a true nonprofit back in the 1990s, measuring and accrediting health plans. And now you've moved much closer to where care is delivered and you touch everything from HEDIS measures into the health plan accreditation into patient-centered medical home. You touch a lot of different things and I want to understand where health equity falls in this big portfolio of work that the NCQA is pushing out. So can you help me understand a little bit more about the health equity team at NCQA and the impacts that you're making across the whole ecosystem, health plans and healthcare, government, employer groups? Want to get a little bit deeper into this, Brian.

Dr. Bryan Buckley (05:52):
Sure. So when it comes to the health equity team, I guess at NCQA, I guess the simplest answer is, "We're all doing health equity," and what I mean by that is NCQA's mission is all about how to improve quality of healthcare. And I'm going to take people back a couple of years ago, back in 2003, with crossing the quality chasm where they defined, "What is high quality healthcare?" And there was six domains in which they define high quality healthcare, efficient, effective, timely, person-centered, but one of the final criteria of what high quality healthcare is is that it's equitable. And so one of the slogans that we often talk about throughout our whole entire organization is, "There can be no high quality healthcare without equity," and so it's every single person's job within NCQA to having that equity mindset as we are looking to advance and improve quality of healthcare.
(06:52):
But the more complex answer is, "Not everyone is able to do everything that's specifically health equity related." I like to think of it as degrees of health equity within our organization. You have the primary degree of locus and the people that are really working on health equity work. So whether it's in our measurement team around HEDIS measures and stratification around race and ethnicity, our research and partnerships with community-based partners, that's the really meat of our health equity work. But then you have the second degree of health equity as we think about our panels, our committees, as we're looking to engage the healthcare ecosystem and making sure that we're doing it in an equitable way. But then there's the third degree, which is to my more simple answer. Everyone is doing health equity because everyone contributes to mission overall in our strategic plan.
(07:42):
And often, I like to say, "We have a Justice League in many ways as a health equity team," and I say that specifically because NCQA, as you've mentioned, we touch a lot of different things, from our policy work, whether it's federal policy, state policy, our product teams which are constantly always looking to advance the work that we do and make life easier for many of the healthcare stakeholders to our research and our measurement and our education. And so think of it like a Justice League. For those are big DC fans, this is [inaudible 00:08:17] right now, where it's the Justice League where we have so many superheroes involved within our company. Look at them in many ways like the health equity champions to help coalesce, "What's the work that's being done in each unit or division?" And that, in many ways, is how we build our team.
(08:34):
Don't think of it so much as a team, but I like to think of myself as the watchtower, really helping to be a space for people to collaborate, talk shop, talk about the challenges that we see from different stakeholders and also think about, "Who do we need to partner with?" "Who's missing at the table," and so forth. And so that is how I would define the health equity team. It's many different people involved in many different departments really building on that collective intelligence that we all need to truly make health equity sustain itself moving forward.

Brian Urban (09:11):
That is an amazing description and probably quite difficult for a lot of other entities across the ecosystem to really understand because your team touches, like you said, HEDIS. You also touch the accreditation programs. They're building products and services as well. There's education and training as well, didn't even mention that. There's so many different bodies of work and it seems like you have a very strong utility team that's been deployed to advance a lot of the work in those areas.

Dr. Bryan Buckley (09:43):
It's still iterating. I'll be the first to say, many organizations that are probably listening, "We don't have a perfect formula on having everything ready," but I think one of the things that I love about our team is we definitely have a growth mindset and the idea of, "We're constantly trying to evaluate, become better." And I think as we talk about health equity, as we talk about process improvement, PDCA, quality improvement, cyclical change, that's really the mindset that I think makes us special because we do really have some really amazing people that are really passionate about this work and it's constantly trying to figure out, "What's the best organizational structure to making sure that we're learning and capitalizing on that collective intelligence across all of our divisions?"

Brian Urban (10:32):
I'm sensing a really agile and almost product-like mindset on the team. It seems like not only do you inform, but you also build, scale, grow, learn how to fail and be able to impact other areas. So it seems like you have your own mini think tank inside the NCQA, if I could be so bold as to say that. But it's an amazing team. I'm a big fan. And want to get a little bit deeper into a couple of your areas that are related to the health equity team that you're helping lead here, Brian. So you do have a lot of programs. I want to talk a little bit about the health plan accreditation framework.
(11:17):
This has been growing in adoption the last year and a half or so here, and some big health plans have signed up. I believe Geisinger was one of them on their health plan side and Highmark, they had gone through this accreditation process to be able to use a lot of your tools and services to help them build out a health equity model for their members and their patients on their care side as well. Can you tell me a little bit about how that's going and any other related work that's influencing the development and maybe future iterations of this accreditation [inaudible 00:11:53]?

Dr. Bryan Buckley (11:53):
Yeah, Brian, I liked what you said right there in the beginning. You said, "Framework," and I think that's important to know for the audience in many ways, because frameworks are a way that we can, in many ways, conceptualize information, and as we've been thinking about this accreditation, we wanted it to be a framework, a guide path for organizations, broad enough where it allows for some experimentation and some really QI, which is what you really need to do health equity, but then also to some degree, a container. And I'm a big fan of Ronald Heifetz's work on adaptive leadership, picking up the heat at a rate that people can tolerate. And I really like that idea and the sense that it does push us and allow us to be more pragmatically brave in the work that we do. And so just to step back, when it comes to our health equity accreditation, I think it's important to know that we've been on this journey for quite some time.
(12:51):
So there's two accreditation programs. There's our Health Equity Accreditation program and our Health Equity Accreditation Plus program. Our Health Equity Accreditation program really had earlier roots back into the early 2010s, 13s, starting from our Multi Health Care Distinction, which for some viewers that have been following NCQA for quite some time, you will remember that. And it was really based off of class standards and making sure that we can get culturally appropriate care when it's needed, making sure that we're investing in interpreters. And so we saw that there was a need back in the earlies, and so this program, as we've learned, as a country we've learned more as the evidence has grown more, we realized that we need to also evolve our programs at the same time. And we can't just look at the class standards because that's one aspect of one person's full identity.
(13:44):
We had to look at people from a whole person perspective and really building on the person-centered care work, which is also a subpart of high quality healthcare. And that's what brought us to Health Equity Accreditation, which is really the matured version of our Multi Health Care Distinction. And so for those that are not as familiar, that's what it is. We decided then to go even further, realizing that when it comes to our Healthcare Equity Accreditation, we realize that part of accreditation, we really need to do ground softening internally. And the one thing that the first accreditation does, that's the base one, is it allows for organizations to really start thinking about internal culture. And internal culture is important when it comes to health equity, because we can only do as good of work externally as we have internally.
(14:37):
Think of the adage, "You need to put your mask on first before you can put your mask on other people." And so we focus a lot on that organizational readiness, and, "Do you have the staffing and the training, the recruitment and the hiring practices in place to really do good health equity work?" We also focus on, "How are you thinking about collecting demographic data on your population that you serve both in your population you serve, but then also internally?" And so I like to think of the base program as a good reflective practice to see, "Are you doing all the things you need to do? Are you analyzing clinical performance and patient experience data? Are you looking at network capabilities and the diversity of your networks?"
(15:21):
That's what the base program, in many ways, is for, and it applies not just for health plans but also healthcare delivery as well, which, as you think of payviders, folks that are large health systems, this also involves them as well. And so just to remind people, our program is not just for health plans but really for the healthcare ecosystem as a whole. Our Plus takes a step further, understanding that as we think about partnerships and equity specifically, we cannot do that in isolation. We cannot have a healthcare-centric way of how we think about health equity because it's impacting people where they live, work, and play. And this is where my public health side comes into play.

Brian Urban (16:03):
Here it comes.

Dr. Bryan Buckley (16:04):
And so this is where we start talking about that. We start building those collaborations with community-based organizations. Those that are closer to the problems see the day-to-day harm, emotional harm, physical harm that is happening to patients where they live, work and play, and can be extremely good amazing partners as we start to build trustworthiness between organizations, between community based organization folks on the ground and health plans, healthcare deliverers, but the healthcare ecosystem as a whole. And so our Plus actually focuses way more on how we think about those cross collaborations and then gets more into interoperability and data governance.
(16:45):
Because after you learn how to collect your data, now it's the bigger responsibility of, "How do you make sure you protect that data and build trust with patients and their families to make sure that you are securing that data in a way that is protecting and not going to be used in a bad way?" So that Plus program really takes it to the next level, which are organizations like Geisinger that you mentioned that were part of our Plus pilot. And so just hopefully that helps with delineating between the Health Equity Accreditation program, but then the Plus program, which we think is the next step forward as you go on your health equity journey.

Brian Urban (17:23):
That is an amazing description, and for listeners, if you're not sold on that, then maybe you weren't paying attention. We'll rewind this and start from the beginning. But I think two amazing things that you said, going back to even the word, "Framework," experimental and guide. There is no turnkey solution for achieving or progressing health equity at the individual level for a population that you serve. So there needs to be a buy-in, take the risk and learn as you do going forward as CEO of Scan Health just said a few months ago, Sachin Jain, "You have to learn as you go and be willing to fail in the right way, and fail forward," sort of phrasing there. And I think that base program is a true enablement level from what I'm hearing, and then the Plus program actually integrating into community-based organizations that are grass root and that could support the needs of individuals that you're identifying as you roll out some of these programs. So just what a great tool set, continuing to evolve over the years. I want to ask you a bold question off that. "What are some early successes you've seen with some of the pilots that you've done with the Plus program?" Any insights you can share with us or version 3.0s on the horizon, things like that?

Dr. Bryan Buckley (18:54):
I don't know if there's any specific examples I can share since we also want it to be psychologically safe for folks to experiment to some degree and we're still learning to some degree. But I can say one of the things, when it comes to the health equity accreditation programs as a whole, it definitely builds on that QI piece. And there's something that you said earlier about failing and failing forward. Just a quick little random side combo here. I remember when I was working on my dissertation. It was on bundled payments for palliative care for [inaudible 00:19:30].

Brian Urban (19:29):
Oh, that was your dissertation?

Dr. Bryan Buckley (19:32):
Yeah. We were experimenting on, "What would it look like to have bundled care for palliative care services?" Mind, during the same time it happened, COVID happened, which, if you're talking about serious illness population, not very good to have those two things interact at the same time. And I remember everything felt like it was burning on fire. I remember my boss and I at the time and my committee, we were thinking about how we could use this as an opportunity to reframe how we thought about things. And we said, "How do we reframe fail?" And fail is figuring out answers and implementing lessons learned. We actually made a whole entire acronym about it. And that is, I think, the key thing around as we talk about those small wins that organizations are having, some of them are going to be really good. And this is why I love the PDCA mindset as a whole, because at the end when you have that A, that act piece, you have essentially three options.
(20:29):
You can essentially abandon an idea and abandoning idea is not necessarily a bad idea because my mother would always say, "It's only truly a failure if you learn nothing from it," so even when you fail at something, how are you figuring out those answers and implementing those lessons learned? You might need to adjust something and say, "Hey, you know what? This didn't work the way we needed it to," and keep in mind that you're doing all these things in collaboration with others and people that are on the front line so you can adjust or you can adapt where you're like, "This is working, let's make it happen." And so the organizations that we see doing this work, and as they're going through their survey process, they are actually putting in essentially their one-year plan as they're thinking about health disparity that they're going to focus on and they're creating QI. Think of it as rapid cycle improvements.
(21:20):
And as we learn more and there's more adoption of the whole entire framework as a whole, we're learning, "What's working? What's not working well?" We're giving people that space of the year as we do those reassessments annually to say, "Okay, how are you doing on X, Y, and Z?" And there's some deep learning that could happen from there, and that allows us to also feed into our research arm to really working with plans to talking about, "What's working? What's not working really well?" And then hopefully provide resources. One of my favorite quotes I tell a lot, I also do some teaching at Georgetown as well for the med school, and I often tell my students, "The cost of life tuition is really expensive so take out these free scholarships that I'm giving you," and I think that's what we're going to eventually see as you talk about Health Equity Accreditation 3.0, 4.0.
(22:11):
We're hoping to take some of those learnings and then actually, to some degree, help build technical assistance and guidance to the field to learning together on what we need to do to really make a more equitable society, to your point, we've never seen before. And so it does require that new learning and that growth mindset.

Brian Urban (22:32):
Great analogy and good plug too. If you have the opportunity to learn from Dr. Buckley, you should take it., go to Georgetown or follow his path, Michigan, then of course, on into Harvard. But wherever you choose, I think you're shaping young minds in a great way. So awesome to hear that as an aside. But to your point, I love the support that you provide and I think for those listening in a health plan or a payvider construct, being able to actually put a plan in place and do it incrementally, to where you were going, is a really rich starting place. And then you'll be able to look at lessons learned, take forward, "What worked well?" and then fit in things that maybe didn't work too well, and then how you can advance. So absolutely love that you're taking that approach because that's a true locked arm partnership approach that NCQA has done since your early beginnings.
(23:32):
So it's great to see that carrying forward. So this leads me into another area, a little bit more specific this way. So obviously, we've had disparities by race, ethnicity, age, gender, preferred language forever. When I look at the news and I look at the challenges that we have across our country, it seems like we're coming to a tipping point. Maybe we've already passed that in terms of helping people get connected to health services. So in thinking about this almost civilization arc of maybe just not helping the people we've needed to help all these years and there's not an infrastructure for mental health in our country or health services at the social health setting, what's the true societal cost, Brian, to the U.S. if we really don't have a health equity centric business model in our ecosystem? What are we going to face here if we don't put this in the middle of our health ecosystem?

Dr. Bryan Buckley (24:38):
I can answer that in a couple of different ways. I think the obvious one, when people think of costs, they think of financial costs. And I know Deloitte last year has done of great work and did a whole study about, "What does it cost us for inequities in our system?" And I believe they were saying it was upward of $320 billion a year with it potentially getting to 1 trillion annually by 2040. And so it really, to your point, is that that tipping point that we really do need to think about, "Okay, how do we actually address not just the disparities, but the underlining inequities that cause the disparities?" Because remember, disparities is just merely the measurement where we see that there's a difference, but then equities become this wicked problem that involve many different stakeholders, require a new way, a reimagining of the system. I actually did a paper last year on health affairs with my buddy Dr. Christopher King, which is the Dean of Health at the Georgetown School of Health, where we actually talked about race, place and structural racism in DC.

And we were actually going back and just looking at, because if you're going to be a good historian... Because you said something earlier, "The lives that we've already impacted," and so when you think of societal cost, we can talk about it from the Deloitte study from that year to year, but there have also been years of lost opportunity to actually address the cost. But then I'm going to say a second aspect of cost that we don't talk about as much is the emotional cost that it actually has on society. I always like to remind people as we're all trying to figure out health equity and for the folks that are like, "Should I invest? Should I not invest in a health equity agenda and being part of the DNA of how I do things?", know that by doing nothing is a choice.

And that there is an emotional toll that it has on people that are experiencing the inequities, whether it's food deserts, whether it's lack of a home, whether it's thinking about not having access to care, not thinking about broadband. And so it involves many different partners, and so I would say in a wrap up of that question, it has both a financial and emotional cost to the work that we do in society as a whole. And that emotional cost, that is probably well above that $320 billion a year, and I think it will only grow as we become a more integrated, more connected society and we're able to see more of the implications and costs that inequities have on our system.

Brian Urban (27:25):
And that's the scary thing is being able to quantify the emotional cost, and we're seeing it almost retrospectively in a lot of ways, especially in the growing gaps in our different socioeconomic levels in our country. And really the challenges of being able to create trust in healthcare again, I think that is one of the biggest barriers we have at a local level across many communities that are challenged economically. So I love where you're taking us. It's beyond financial.

Dr. Bryan Buckley (27:57):
[inaudible 00:27:57], not just about building trust, but making sure that as health stakeholders, we are trustworthy, which I think goes into the ongoing process. Trust is the outcome measure. The process measure is trustworthiness that we have to build into our systems. And that's the hard work.

Brian Urban (28:14):
Thank you for framing it that way because that's the outcome we want to achieve is, "Hey, we now have trust, but are our healthcare systems seen as trustworthy and how can that glue happen between community members and healthcare professionals and systems?" So thank you for separating that and, see, I got to join your class. I'm still working through more academics, but maybe I get a chance to sneak into Georgetown and take some classes from you.

Dr. Bryan Buckley (28:43):
We have an amazing executive master's program on quality and safety.

Brian Urban (28:48):
What's another master's? Why not? But I love the conversation we've had and I think you've really spoken some great truth as to, "Hey, it's a choice if you don't invest into health equity as a part of your operations as a health plan or healthcare delivery organization, et cetera," and who you work with at all levels, your base program, your Plus program, your research side, education and training side, it's such an amazing shop that you have and I'm just such a big fan. But I want to take us into the future now. So if we could go down the road maybe, let's say two, three years from now, Brian, what do you think is going to be the top impacts the NCQA health equity team specifically will have in the healthcare ecosystem?

Dr. Bryan Buckley (29:44):
That's a great question. I can tell you more what my hope is, and it's often based off a framework I always say is like, "What's the story we're going to tell of ourselves in the future? But then what is the story people are going to say about us?" And I guess I would say I would hope that through our programs, because even as we have our strictly health equity accreditation programs and educations as you mentioned, we're also taking an audit of all of our programs that we've ever had to making sure that they were equitable from the start. And so I hope that in the next two to three years, that there is more intentionality that you'll see from us around this space, around health equity. We will help build structures. One of my favorite quotes by Deming is, "Every system is perfectly designed to get the results it gets."

And I hope through our standards and our accreditation programs and our research and our education and all that we put out, that we will help create a system where there will be more authentic partnerships. There will be more co-creation with community-based organizations and patients and families. We'll harness data a lot better. Hopefully by then, we'll have seen the impacts of our stratification by race and ethnicity data through our HEDIS measures on, probably by that point, about 13 measures by then. We'll have better quality measurement. We'll build capacity, building with organizations because especially with that Plus program, building those community networks and making sure that folks are working with each other. But I think that is my view of hopefully what the future looks like, that I think, as I said, to be more intentional and that we create cross-sectional partnerships through the work that we're doing, aligning not just with the government and the states, but really with the patients and the family members that are truly impacted by the work.

Brian Urban (31:35):
I really took note of where you said the HEDIS measures will go. You cover about 200 plus million people today, but that's going to grow and you're going to have even more precise insights to share and connect. That is going to be truly impactful across the ecosystem, aside from all of the amazing work you're doing at core in the health equity team. So just such an exciting conversation and a cool shout out to Dr. King. I feel a follow up episode coming on. Who knows? You never know. But Dr. Brian Buckley, thank you so much for joining the show and for more excerpts and insights, please join us at finthrive.com. Thanks, Brian.