—and Why You Should Care
Ethics, liability, and financials are all in play as healthcare organizations consider their role in addressing disparities. A person’s health—and the quality of care they receive—shouldn’t depend on their skin color, ZIP Code, level of education, or income. Yet for many Americans, these disparities are real.
What’s new is that the pandemic and racial tensions in our country over the last 18 months are shining a spotlight on the problem. We’re more aware than ever that health and healthcare delivery aren’t always fair, and that the problem is exceedingly difficult to solve.
Lack of concern or will are not always to blame, says clinical bioethicist Janine Siegel, PhD, who works at MultiCare, the largest not-for-profit health system in the state of Washington. “Every healthcare system wants to deliver equitable healthcare—it’s the right thing to do for their communities and ultimately creates a financial benefit for the organization,” Siegel says. “But to achieve equity, society has to address obstacles to health that involve poverty, discrimination, health-insurance costs, food deserts, community distrust, and a host of other issues that are beyond a hospital’s direct control.”
Efforts to solve the issue remind Siegel of a quote by the naturalist John Muir: “When one tugs at a single thing in nature, he finds it attached to the rest of the world.” Every tug at the issue of health equity reveals new complexities.
HEALTH EQUITY AND HEALTH EQUALITY
Health equity and health equality are related, but not the same. Health equality is a one-size-fits-all approach that means everyone receives the same resources to be as healthy as possible. Unfortunately, many social and environmental factors can limit a person’s access to these resources.
The Robert Wood Johnson Foundation has made health equity a priority over the years, believing that equity happens when “everyone has a fair and just opportunity to be as healthy as possible.” This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and healthcare.
Sarah Dryfoos-Guss, health equity and outreach program manager at MultiCare, describes it this way: “I think of health equity as a strategy that can be used to achieve equality. This strategy can reduce disparities and enable people to live happy, healthy, full lives. Something that gets missed is that equitable approaches are good for everyone. It’s not a zero-sum game where if we invest in one group, we neglect another. If we share more resources with those who need them most, the entire community can benefit.”
FOCUSING ON RACE FIRST?
Dryfoos-Guss points to the example of MultiCare’s COVID-19 vaccination campaign earlier this year. MultiCare worked with community partners at the Tacoma–Pierce County
Health Department to identify which demographic groups were disproportionally experiencing COVID-related disease burdens and which groups had lower vaccination rates. People of color—especially Black, LatinX, Native Hawaiian, and Pacific Islander populations—were highly represented in both groups. Dryfoos-Guss and their team focused their vaccination efforts on improving access for these communities.
“The literature shows that when you focus on race first when trying to close gaps, all other identities and demographic groups benefit,” DryfoosGuss says. “Otherwise, race persists as the most negative cause of ill health. So we focused our vaccine strategy to ease burdens for communities of color, built trust with community members, and rolled out vaccines toanyone who wanted them. This strategy helped people feel cared for, and that was important to us.”
The vaccine drive is one of many outreach programs that Dryfoos-Guss and their colleagues at the MultiCare Center for Health Equity and Wellness have offered this year. Current programs and services focus on improving healthcare for LGBTQ+ patients, improving how the system collects and analyzes data, and increasing culturally informed care for all providers. In addition, the center provides free community health screenings, conducts community events, and offers community nutrition services.
Like all other not-for-profit health systems, MultiCare conducts a community health needs assessment every three years. This helps them prioritize where to invest to address
health inequities and make the greatest impact on people’s lives.
“Many health systems lack the resources to do outreach to the extent that MultiCare can,” Siegel says. “But hospitals of any size can partner with other organizations to address the social determinants of health, find inefficiencies that create barriers to care, and grow equity so that everyone prospers.”
THE RISKS OF INACTION
The risks of not addressing health inequities are significant, creating population-health, financial, and liability problems. A few examples:
- Poor health outcomes. According to the American Hospital Association, an individual’s life expectancy can vary by as many as 25 years between neighborhoods in some U.S. cities, with similar outcome gaps in infant mortality, obesity, violence, and chronic disease also occurring in these areas.1
- Increased costs. Hospitals often absorb the cost when patients lack insurance, are underinsured, or are otherwise unable to pay for their healthcare. This can mean millions of dollars in free and discounted care, raising overall healthcare and insurance costs for insured patients.2
- Liability. Legal action against a provider for alleged discriminatory practices that contribute to health inequity can tarnish an institution’s reputation and result in financial loss.
In short, health equity matters—a lot.
PARTNERSHIPS CAN MOVE THE NEEDLE
Since no one organization can do it all, a partnership approach is essential to achieving health equity. It allows health systems and local organizations to share resources and ideas and develop efficient, effective solutions.
A partnership at MultiCare that included the Pierce County AIDS Foundation and other community-based organizations is fueling the success of an innovative initiative to create an
LGBTQ+ provider directory, DryfoosGuss says. “There is a huge disparity in care for the LGBTQ+ community, especially in terms of underdiagnosed mental health issues that can increase the risk of depression and suicide,” they say. “The directory will allow LGBTQ+ patients to find providers who are informed about LGBTQ+ healthcare needs and will help our LGBTQ+ patients receive the care they deserve.”
Dryfoos-Guss and other stakeholders worked with community members and local LGBTQ+ organizations, along with national groups, to develop thresholds of what it means to be LGBTQ+-affirming. (There is no national standard at this time.) They are now developing a process that allows providers to self-identify as LGBTQ+-affirming and are creating a webpage to make these providers easy to find.
DISRUPTION AND INNOVATION
Many social determinants of health—poverty, educational opportunities, and housing access, to name a few—are deeply entrenched, which makes achieving health equity elusive. Lasting change requires a disruptive mindset to envision new solutions. It’s that mindset that led Navicent Health (now Atrium Health Navicent) to establish a Center for Disruption and Innovation in 2015. The combined efforts of the health system, with support from the center’s novel technology, would eventually resolve readmission disparities among Black patients with chronic obstructive pulmonary disease (COPD), heart failure, and diabetes in a scalable and sustainable manner.
The road was far from easy, says Simeon Sessley, who served as executive director of the center for three years after its inception. Navicent Health’s president and CEO at the time, Dr. Ninfa Saunders, was determined to have the center invite as many partners to the table as possible in its efforts to close disparity gaps. More than 50 “clinicians, community members, and creatives” signed on, Sessley says. The center, and its expert team of project managers, nurse researchers, PhD scholars, and innovative physicians, was based in
Macon, Georgia. It brought together:
- Startup companies and scholars from Georgia Tech, State University of New York-Binghamton, and the Massachusetts Institute of Technology, and from as far away as Australia
- Physicians who specialize in serving communities needing significant diabetes and cardiology care
- Adults and teens from the community “Health equity is multi-layered and complex, and there’s no one-size-fits-all answer or quick solution,” says Sessley. “You have to find the right resources and include experts with different perspectives. We wanted to take a scientific approach to solve problems that would allow us to tinker and tweak as we went along. This type of intricate work can be daunting, and doubt can set in. But we found ways to create ownership and keep each other motivated.”
TAPPING THE INNER SCIENTIST
Clinicians and creatives teamed up at Navicent to analyze diabetes and heart-disease data, looking for clues to explain health disparities experienced by Black patients. Among their strategies:
- Examining operations and clinicalcare practices to find opportunities to improve efficiency and impact
- Considering socioeconomic factors that could be affecting patient compliance, such as lack of transportation and housing insecurity
- Inviting community feedback on ideas, including hosting a “hack-a-thon” for college and high-school students to weigh in on potential solutions
Eventually, these teams evaluated more than 230 pilot programs, which they presented to a panel of clinicians, administrators, foundation leaders, and community members, who in turn selected 12 startups for funding. One pilot program that received funding was based at a federally qualified health center (FQHC) in Georgia. The program recruited a group of patients with diabetes who had been seen at the center more than seven times the previous year.
Each patient received a tablet, free WiFi, a digital health app, a food scale, and other technology and followed a regimen to improve their blood-glucose control. In one year, 75 percent of high-risk patients reduced their hemoglobin A1C by an average of 2.3 points. (High A1C levels are associated with worse bloodglucose control and a higher risk of diabetes complications.) Two other Navicent Health FQHCs adopted this program with similar success. “Working on projects like this was a welcome change for physicians,
so many of whom are fatigued by keeping up with other administrative tasks while still going above and beyond for their community,” Sessley says.
“They enjoyed tapping into their inner scientist, mentoring young startup folks, and solving problems that had not only a financial impact on the hospital system but a health-equity impact as well.”
In 2018, the American Hospital Association recognized Navicent Health for its commitment to reducing health disparities with the Equity of Care Award. The AHA noted the organization’s “measurable steps to improve diversity, inclusion, and health equity…and comprehensive gains in addressing the health disparities in the community it serves.”
About a year later, Navicent Health merged with Atrium Health. Sessley led the Center for Disruption and Innovation through the transition until it relocated to Atrium Health’s headquarters in Charlotte, North Carolina, where the work continues. He then founded Advisory Trail, a consulting practice that has helped companies such as Walmart
Health and Wellness develop new products and ideas.
“Winning awards was exciting,” Sessley says. “But what made all of us really happy was the chance to achieve sustainable health outcomes with patients who previously lacked the resources to do so.”
When people set aside their preconceived notions, unconscious biases, and established ways of looking at the world, these types of outcomes are possible, Siegel says. “The work is difficult, but if we can learn to listen to each other and explore new ideas, we can break down longstanding barriers to health equity,” she adds. “The end goal is healthy communities, which are foundational to a healthy and economically vibrant society.”