At times, Dr. Joseph Wright, chief health equity officer at University of Maryland Medical System, feels like he's playing catch up.
One year into his tenure at the Baltimore-based provider, Wright has been retracing the annals of medicine to uncover antiquated science and biases that may still be embedded in clinical care.
He sought out and eliminated race factors from decades-old risk calculators and other clinical support tools providers still use that contribute to worse health outcomes for people of color.
Wright also launched efforts to stratify safety and quality data by race and ethnicity to reveal disparities. Now, he is collaborating with researchers and medical schools to refresh the scientific record and train the next generation to provide more equitable care.
“A lot has changed in the landscape, and I think the industry is more keenly aware of systemic inequities that have existed,” Wright said. “But now the bad data has been ripped away, and it's quite evident that we have a responsibility to not only address disparities, but to very deliberately unwind the practices that often lead to these disparities.”
Wright is among a growing cadre of healthcare executives specifically tasked with fulfilling the industry's longstanding promises to address inequities and disparities. This entails confronting centuries of organizational and clinical practices that are either influenced by discredited racist notions or fail to reckon with the health consequences of racism and the special needs segments of the population have because of their races, ethnicities and other attributes.
The existence of these recently minted executives emerged from a shift in strategy among healthcare organizations that prioritizes eliminating health disparities. The movement went mainstream as the nation grappled with the COVID-19 pandemic and the murder of George Floyd in 2020, said Dr. Margaret Larkins-Pettigrew, chief clinical diversity, equity and inclusion officer at Pittsburgh-based Allegheny Health Network, who started her role in November 2020.
Health equity leaders are trying to sustain that momentum and transform clinical practice, workforce development and public health while moving on from the traditional fee-for-service business model. To achieve success, these executives must steer their employers away from one-off investments and toward long-term operational systems and clinical models that improve healthcare for underserved people.
They have catalyzed efforts to collect race, ethnicity, sexual orientation and other identity data for safety and quality analyses, which they use to understand how outcomes vary among specific populations. Using those data, health equity leaders are working alongside academics, clinical teams and trade associations to reevaluate clinical tools and practices that contribute to disparities. They have also launched efforts to screen patients for social determinants of health and are establishing cross-industry partnerships to connect people to community resources.
“We know what our targets are. We are just knocking them down, one at a time.” Wright said. “Yeah, we’d love to move faster. But we know, directionally, that we’re going the right way.”
The business case
Health equity leaders are aligning their goals with the future of value-based care and gathering data to back them up.
A Deloitte report published this year estimates that disparate health outcomes could cost the U.S. healthcare system $1 trillion annually by 2040, nearly tripling in size over the next 20 years and accounting for 12.5% of healthcare spending.
The annual cost of excess health services delivered due to disparities is $320 billion, and the rate of increase outpaces overall spending trends, according to Deloitte. The consultancy advises providers to shift to value-based care arrangements that encourage efficient, high-quality care. The financial rewards would grow if providers were to close the gaps, Deloitte reports, which health equity leaders emphasize to drive change in the market.
“It’s actually saying health equity is our business and basis for competition. You need to change the frame to say it’s not on the fringe, separate and distinct. It needs to be embedded in all of it.” said Dr. Kulleni Gebreyes, U.S. chief health equity officer for healthcare consulting at Deloitte, who started the newly created role in February.
These financial incentives tie directly into initiatives from the federal Center for Medicare and Medicaid Innovation. Centers for Medicare and Medicaid Services leaders are pushing organizations to participate in accountable care models that include equity measures.
Disparities in communities and clinical care
The task of identifying and solving disparities is underway as hospitals gradually take on more financial risk. By adding race, ethnicity, language, sexual orientation, ZIP code and other data to health outcomes, providers can take a more holistic view of what affects patient health and take action to address those factors.
For example, by stratifying maternal health outcomes by race, providers have found that Black women are nearly three times more likely to die during pregnancy than white women. Those findings have prompted organizations to expand access to doulas, midwives and other resources that research has demonstrated improve quality.
Healthcare organizations are employing similar efforts to solve for other disparities, which usually involve forging partnerships that reach beyond clinical care.
The Allegheny Health Network established a program alongside more than 40 community-based groups to expand prenatal, perinatal and doula services in an attempt to decrease Black infant mortality in Pittsburgh.
CVS Health launched “health zones” in five ZIP codes with high poverty levels where the company is working to increase access to food, transportation and healthcare. CVS collaborates with Uber Health to coordinate rides to appointments, food pantries and safety-net providers.
Blue Cross and Blue Shield of Minnesota partnered with TurnSignl to pilot a smartphone app that provides on-demand legal services during traffic stops after the high-profile manslaughter of Daunte Wright by a police officer took place in April 2021.
“If you just embed equity in how you make decisions, that’s how you will be able to move the needle,” said Dr. Joneigh Khaldun, chief health equity officer at CVS Health, who started her position in October 2021.
When clinical care needs to be updated to rectify disparities, health equity leaders work within the “just culture” framework to educate providers on new practices and address bias in care. That requires creating an environment of "cultural competence and humility," Larkins-Pettigrew said.
Larkins-Pettigrew distributed a diversity engagement survey to Allegheny Health Network employees to assess where biases existed and what training was needed. She also works with employee resource groups and appointed 125 people to lead diversity, equity and inclusion within every department so that discussions occur in smaller groups among peers, she said.
“You are stepping into a space where people are very uncomfortable—and you are uncomfortable—but you’re the one who is responsible for leading the way to a comfortable place where people feel as if they can talk about those issues that will make a difference in the lives of everybody,” Larkins-Pettigrew said.
The next generation of doctors
Health equity leaders aim to refresh the science of health disparities by tapping academic institutions and industry groups to update curricula and build a new, robust body of research and standards. Organizations such as Sutter Health and Baltimore-based Johns Hopkins Health System have launched health equity institutes that bring together executives, clinicians, researchers, educators, data analysts and policy experts to develop solutions.
Sutter Health's institute has published research that shows racial bias linked to pulse oximeters delayed care for Black COVID-19 patients for up to 4.5 hours. Another study determined that pregnant Hispanic patients were 2.4 times more likely to contract COVID-19 than pregnant non-Hispanic white patients.
“We have to start small and move fast,” said Leon Clark, chief research and health equity officer at Sacramento, California-based Sutter Health, who started his role in April 2020. Creating more equitable outcomes requires an “all-hands-on-deck” approach, he said at HLTH 2022 in Las Vegas last month. It’s important to build out strategic partnerships and bring in the patient perspective when identifying problems and creating new care models, he said.
At the University of Maryland Medical System, Wright and University of Maryland School of Medicine leaders weed out race-based medicine and outdated clinical practices in medical education, he said. He also works closely with trade associations to establish standards for clinicians in different specialties.
Wright is a board member for American Academy of Pediatrics and chairs the equity committee. He was the lead author of a policy statement published in August that calls for the end of race-based medicine and recommends healthcare organizations and medical societies identify and eliminate guidelines that use race as a factor for clinical decisions.
Wright subsequently announced that the University of Maryland Medicine would remove race as a variable in the Vaginal Birth After Cesarean calculator, a widely used tool to determine whether patients giving birth should undergo cesarean sections if they previously had one. The race adjustment caused more Black and Latino people to get C-sections than needed them, Wright said. Instead, the University of Maryland replaced that factor with chronic hypertension, which is better indicator for birthing outcomes, he said.
“The only way to sustain and to systemize these corrective actions that we’re doing is to build it into the training,” Wright said. “It's transformative work. It's a generational work. And I think we would all be naive to expect that we're going to unwind all this stuff in 10 years. We have a bit of a heavy lift.”
