Examining alignment of community health teams' preferences for health, equity, and spending with state all-payer waiver priorities: A discrete choice experiment

Abstract

Objective: The state of Vermont has a statewide waiver from the centers for medicare and medicaid services to allow all-payer Accountable Care Organizations (ACOs). The Vermont all-payer model (VAPM) waiver is layered upon previous reforms establishing regional community health teams (CHTs) and medical homes. The waiver is intended to incentivize healthcare value and quality and create alignment between health system payers, providers, and CHTs. The objective of this study was to examine CHT's trade-offs and preferences for health, equity, and spending and the alignment with VAPM priorities.

Data sources/study setting: Data were gathered from a survey and discrete choice experiment among CHT leadership and CHT team members of the 13 CHTs in Vermont.

Study design: We used conditional logit models to model the choice as a function of its characteristics (attributes) and mixed logit models to analyze whether preferences for programs varied by persons and roles within CHTs.

Data collection/extraction methods: There were 60 respondents who completed the survey online with 14 choice tasks, with three program options in each task, for a total sample size of 2520.

Principal findings: We found that CHTs prioritized programs in the community health plan and those with quantitative evidence of effectiveness. They were less likely to choose either programs targeting racial and ethnic minorities or programs having a small effect on a large population. Preferences did not vary across individual or community attributes. Program priorities of the VAPM, especially healthcare spending, were not prioritized.

Conclusions: The results suggest that the new VAPM does not automatically create system alignment: CHTs tended to prioritize local needs and voices. The statewide priorities are less important to CHTs, which have excellent internal alignment. This creates potential disconnection between state and community health goals. However, CHTs and the VAPM prioritize similar populations, indicating an opportunity to increase alignment by allowing flexible programs tailored to local needs. CHTs also prioritized programs with a strong evidence base, suggesting another potential avenue to create system alignment.

Keywords: healthcare organizations and systems; program evaluation; sampling; social work; survey research and questionnaire design.