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Turning Health Equity into Outcomes 

Accountable Care Organizations (ACOs) are at the forefront of a transformative shift in healthcare—one that moves beyond clinical care to address the broader social and structural factors that shape health outcomes. Turning health equity into measurable results requires more than good intentions; it demands data-driven strategies, inclusive communication, and targeted interventions. 

The Equity Gap: What the Data Shows 

Health disparities persist across racial, ethnic, and linguistic lines. A study of 11 ACOs in Massachusetts found that equity in ambulatory care quality did not significantly improve between 2019 and 2022. In fact, performance declined for Asian patients in breast cancer screening by 3.52 percentage points and similar declines were seen in cervical and colorectal cancer screenings for other minority groups6. 

CDC data from the Behavioral Risk Factor Surveillance System (2022) revealed that social isolation affected 31.9% of U.S. adults, while 24.8% reported lacking emotional support. These issues were significantly more prevalent among Black, Hispanic, Native American, and multiracial adults compared to White adults7. 

Language barriers compound these disparities. In the U.S., 26 million people—about 8% of the population—have LEP2. Latino patients with language-discordant providers were over 10 times less likely to fully understand their medical visits. Among those patients, 80.8% needed help understanding instructions, and 35.1% had no support available8. Limited English proficiency (LEP) is associated with delayed diagnoses, medication errors, and poor chronic disease management⁴. 

Data as a Driver of Equity 

SDOH data—covering housing, food access, transportation, and more—can be integrated into predictive risk models to identify patients at higher risk of poor outcomes. For example, two patients with hypertension may have vastly different risk profiles depending on their social context. Without SDOH data, care teams may miss critical barriers like housing instability or food insecurity that drive emergency visits and poor adherence⁵.  

Actuaries and care managers are increasingly using SDOH-enhanced models to refine cost forecasting and target interventions. These models outperform traditional ones by revealing hidden risks that claims and clinical data alone cannot capture9. 

Speaking the Patient’s Language 

Language is more than a tool for communication—it’s a gateway to trust, understanding, and effective care. Effective communication is foundational to equitable care. Tools like Sophie, a virtual assistant capable of speaking many languages, help bridge the gap by engaging patients in their preferred language. This not only improves understanding and trust but also enhances adherence and satisfaction. 

Equity Weighting: A New Measurement Framework 

Traditional quality metrics often overlook disparities. A new framework—equity weighting—proposes adjusting quality scores to reflect outcomes for underserved populations. This approach aligns incentives with equity goals and ensures that improvements benefit all patients, not just the majority1. 

The Role of Payment Reform 

The National Quality Forum’s roadmap outlines a four-part strategy: 

1. Identify and prioritize disparities 

2. Implement evidence-based interventions 

3. Develop equity performance measures 

4. Incentivize disparity reduction 

Yet, most current programs—including ACO models—do not directly reward equity improvements. Without targeted incentives, even well-intentioned efforts may fall short3. 

A Path Forward 

Turning health equity into outcomes requires: 

  • Robust data collection on social needs 

  • Stratifying outcomes by race, ethnicity and language 

  • Cross-sector collaboration beyond healthcare, including partnering with community organizations 

  • Using predictive models to prioritize care for socially vulnerable patients 

  • Implementing multilingual tools like Sophie to improve patient engagement 

  • Policy support for equity-focused reimbursement 

ACOs must move beyond identifying disparities to actively dismantling them. This means embedding equity into every layer of care delivery—from clinical decision-making to strategic planning. 

Conclusion 

Health equity is not a side initiative—it’s central to quality care. By leveraging data, addressing language barriers, and integrating SDOH into care management, ACOs can turn equity into outcomes. The path forward requires bold leadership, smart technology, and a commitment to listening—especially in the language patients understand best. 

References (AMA Format) 

  1. Agniel D, Cabreros I, Damberg CL, et al. A formal framework for incorporating equity into health care quality measurement. Health Aff. 2023;42(10):1383–1391. 

  1. Gonzalez-Barrera A, Hamel L, Artiga S, Presiado M. Language Barriers in Health Care: Findings from the KFF Survey. KFF. 2024. https://www.kff.org/racial-equity-and-health-policy/language-barriers-in-health-care-findings-from-the-kff-survey-on-racism-discrimination-and-health 

  1. National Quality Forum. A roadmap for promoting health equity and eliminating disparities: The Four I’s for Health Equity. NQF. 2017. https://cms.qualityforum.org 

  1. Pandey M, Maina RG, Amoyaw J, et al. Impacts of English language proficiency on healthcare access, use, and outcomes among immigrants: a qualitative study. BMC Health Serv Res. 2021;21:741. 

  1. Popowitz E. How SDOH data is used in healthcare risk management. Definitive Healthcare. 2025. https://www.definitivehc.com 

  1. Rodriguez HP, Xu S, Brewster AL, et al. Accountable care organization changes in equity of ambulatory care quality by patient race and ethnicity, 2019-2022. Health Aff Scholar. 2024;2(12):qxae155. 

  1. Town M, Eke P, Zhao G, et al. Racial and ethnic differences in social determinants of health and health-related social needs among adults—United States, 2022. MMWR. 2024;73(9):204–208. 

  1. Volz N. The unseen challenge: The impact of language barriers on patients in healthcare. ReImagine Healthcare. 2023. https://www.reimagine-healthcare.org 

  1. Zuskov D. Taking social determinants of health (SDoH) from data to analysis and action. Healthcare IT Today. 2023. https://www.healthcareittoday.com