How health systems can tackle health disparities

After more than a decade of asking why factors such as race, ethnicity, income, gender and sexual orientation often correlate with worse health and healthcare quality for so many Americans, perhaps the biggest question is what can healthcare providers do about it.

Some policy experts say the solutions are beyond the reach of healthcare organizations.

“I think there's a view in this country that this can all be solved by healthcare,” said Lisa Dubay, a senior fellow at the Health Policy Center for the Urban Institute. “There's this whole world out there that contributes outside of the doctor's office to these types of disparities, and I think it's hard for the healthcare system to fix those.”

Increasing insurance coverage and access to providers for underserved populations has been the primary focus. Indeed, research shows the coverage expansions under the Affordable Care Act have helped move the needle on health disparities among racial, ethnic and socio-economic groups.

But some providers and researchers are also realizing that's just the starting point, and the healthcare system needs to make deeper changes and take on new roles. The issue promises to be an even greater concern for healthcare organizations in the coming years. The U.S. Census Bureau projects the number of Americans who identify as being an ethnic or racial minority will surpass whites as the majority of the U.S. population by 2043.

Last week, the National Institutes of Health launched two centers that will study the impact of environment—the family, local community, healthcare system—on a person's health.

The centers will serve as regional hubs for community organizations, doctors, nurses and institutions to collaborate on health interventions.

Much of the work involves engaging with problems rooted in nonmedical factors such as poverty, housing, hunger and racism—foreign territory for most healthcare organizations, according to pioneers in such efforts.

“A misconception is that once you provide access and give everyone an insurance card, they'll be fine and they'll all just start knocking on the door and making appointments,” said Dr. Kimberlydawn Wisdom, senior vice president of community health and equity for Detroit-based Henry Ford Health System. “That's just not the case.”

Wisdom said Henry Ford has built trust by establishing relationships with community members for more than a decade.

Safety net providers have long viewed narrowing health gaps as part of their mission. Other providers are now starting to pay more attention to disparities as they try to generate cost savings by reducing the frequency and intensity of healthcare services delivered to patients who tend to need the most care.

About 26% of blacks and 24% of Hispanics in the U.S. were living in poverty in 2014, compared with 10% of whites and 12% of Asians, according to a 2015 HHS status report on the country's health. And people with lower incomes are much more likely to have poor health outcomes.

A white paper by the Institute for Healthcare Improvement found that the relative risk of mortality from any cause decreased as the level of household income increased. People in households earning $25,000 or less a year had a mortality risk three times higher than people in homes with an annual income of $115,000 or greater.

Racial and ethnic disparities were estimated to cost the U.S. about $60 billion in excess medical expenses in 2009, according to the IHI report, and the sum is projected to reach $353 billion by 2050.

The economic burden creates some urgency for healthcare providers to identify and embrace more comprehensive strategies than hosting occasional wellness screenings at community events or offering employee training on cultural competence, said Dr. Kedar Mate, chief innovation and education officer at the IHI and one of the authors of the white paper.

“We started thinking about how healthcare organizations could reach beyond those issues,” Mate said. “We began to think about where they build their hospitals, how they think about the workforce that they employ, how they can make connections to the community in a different way and promote the kind of healthy interactions that people really need in order to live better lives.”

The IHI's report offers recommendations to help providers develop a framework for achieving health equity. The first is to show a commitment to the cause at all levels of the organization. A key part of that commitment is finding sustained funding for health equity programs by transitioning from fee-for-service contracts to payment models that reward providers for care coordination and health outcomes.

Wisdom said securing reimbursement to support Henry Ford's efforts was a challenge five years ago as the system led a partnership of local and state public health agencies, community groups and other health systems to develop its “Sew Up the Safety Net for Women & Children” program.

The initiative involves training community members to be healthcare workers who then assist at-risk mothers during home visits in the Detroit area, which has one of the highest infant mortality rates in the U.S.—nearly 15 deaths within the first year of life for every 1,000 live births.

The program has had 200 mothers participate since its start, with no infant deaths. Despite that success, Wisdom said, the state's Medicaid program offers no reimbursement for community healthcare workers. “We have had to be very creative in how this model is supported.”

But the program's fortunes may soon improve. The system's healthcare clinics have committed to provide additional funding. Also, talks are underway with health insurance plans to pay for community healthcare workers. “We started off with a grant model, but we're looking for that sustainability,” Wisdom said.

A key part of Henry Ford's efforts—and one identified as crucial in the IHI report—has been collecting data to measure results and demonstrate the effectiveness of its strategies.

One area often overlooked in addressing health disparities is the role of institutional racism or bias, which can include factors as seemingly innocuous as hospital parking fees that are cost-prohibitive for some patients.

“There is some evidence that there are differences in the way some patient populations are treated, whether it's some implicit bias toward particular groups or a financial motivation,” said Ani Turner, co-director of the Center for Sustainable Health Spending at the Altarum Institute. “I think there's a need for gathering data and looking at it on how you're treating your patients, and then breaking that out by race and ethnicity to see if there are systematic differences and addressing them if there seems to be a problem.”