Health inequity in America is by no means a recent phenomenon. But Covid-19 and its disproportionate toll on communities of color have shone a harsh light on the extent of the problem and the urgent need to tackle it. While there is no easy, overarching solution, experts believe the first step is simple: start listening.
As providers and payers do so, they are learning that their role in mitigating care gaps will require collaboration with trusted voices in minority communities. It will also require them to up the ante on addressing social determinants of health.
So, providers and payers are joining forces with community-based organizations and data startups to gain a better understanding of the people they serve. They are also investing in underserved areas and providing access to necessary resources, like fresh food and high-speed internet.
Further, these healthcare stakeholders are looking within and working to root out the implicit biases that are entrenched in the corporate and organizational culture.
Understanding the problem
You can’t solve a problem that you don’t understand so foremost is understanding that there is no racial link between minorities and their propensity for diseases like Covid-19. This is what Dr. Jaya Aysola, chair of Pittsburgh-based Penn Medicine’s Health Equity Alliance, wants people to understand.
“There is a nuanced story here that needs to be told in a way that doesn’t pathologize people from a certain race or ethnicity,” she said. “We assume that differences that we see [in health outcomes] by race and ethnicity, which are social constructs, are somewhat due to something intrinsic to that population. But what we know is that is not the case. It’s not something genetic, it’s not personal agency or lack thereof — it’s structural inequities.”
There are two ways in which structural inequities manifest in the healthcare system. One is within a hospital facility, where those from minority communities often receive lower-quality care. The other is between hospitals, where those groups tend to receive care at facilities with lower quality scores overall, Aysola said. This double whammy can create the illusion that minority populations are more susceptible to certain chronic health conditions.
An added complexity is that for Black, Indigenous and people of color (BIPOC) groups, the lack of trust in healthcare institutions isn’t just based on their own experiences — it is passed down from generation to generation, said Dr. Aletha Maybank, senior vice president and chief health equity officer for the American Medical Association, in a phone interview.
Stories of exploitation and experimentation — like the infamous Tuskegee study — cemented the mistrust in healthcare that now exists among these communities.
The initial lack of information about the new coronavirus, as well as the problems around equitable access to testing and vaccination
, have exacerbated the already strained relationship between physicians and the minorities they serve, she said.
“We have to reframe how we talk about trust and really focus less on the language of trust, and more so on what are the institutions — [and] what is the physician who is a part of those institutions — going to do differently,” she said.
Providers’ strategies to build back trust, improve care
The best thing providers can do to begin closing care gaps and rebuilding trust is to engage in a dialogue with the BIPOC and other at-risk communities.
“We know that historically there has been systemic racism in the healthcare system in every aspect, from healthcare delivery to the training of our professionals to the scientific studies that have been done,” said Dr. Takeisha Davis, CEO of New Orleans East Hospital, April 19 during the virtual MedCity INVEST conference on a panel about health equity and the need to build trust. “We need to acknowledge, openly, loudly, that there were flaws in the way we treated minority communities which have led to the underlying healthcare disparities that we see today.”
Not only do providers need to speak openly about racism, but they also need to shed the paternalistic nature of their work. Instead of riding up like the proverbial knight in shining armor and assuming to know what BIPOC, LGBTQ and low-income groups need, providers should first just listen.
“We need to first understand the felt needs of people…and then partner with them,” said Dr. Adam Myers, chief of population health and director of Cleveland Clinic Community Care, at INVEST.
Health systems often make the mistake of establishing a clinic in a community without considering that there may already be others in the area that have engaged in public health work for decades, he said.
This is why Cleveland Clinic is joining with trusted voices, like community-based organizations and places of worship, to expand access to care. The health system worked with United Pastors in Mission, a large group of pastors, who helped distribute personal protective equipment to churches in the community.
The provider also collaborated with Fairfax Renaissance Development Corporation and other local partners on two outreach events, where health education materials and information on social services were gathered and stuffed into the 300 bags for community members.
But Cleveland Clinic’s health equity work goes beyond these partnerships and includes making capital investments in the areas they serve. For example, in December, the health system joined forces with area businesses to provide high-speed internet at subsidized prices to residents of an underserved Cleveland neighborhood.
Like Cleveland Clinic, New Orleans East Hospital has identified gaps in social services that have an impact on patient outcomes, CEO Davis said. The hospital has created a Community Activation Board, which uses data pulled by the facility to pinpoint key needs for specific populations.
One such need was additional support for diabetics. The hospital learned that many of their clinicians’ recommendations for diabetics, like walking more and eating better, were out of reach for patients. So, they created a walking trail on their campus and organized a farmer’s market twice a month for community members, Davis said.
Penn Medicine employed a similar strategy during the pandemic and established a social needs response team, said Aysola, chair of its Health Equity Alliance. Accessible through a call center, the team focused on helping those who needed to quarantine but couldn’t due to a lack of resources. The team delivered food to houses and found hotels for people to stay in, among other interventions.
Further, Penn Medicine has set up dashboards to measure its progress in the health equity arena, Aysola said. If clinicians see the outcomes for a particular demographic group suddenly change or skew negatively toward a particular population, they examine the issue and intervene. First, they investigate in-house factors, like the biases intrinsic to the hospital staff, and then they consider patient-related factors, such as whether the patient came to the hospital later than they should have, she said.
“The generalized approach is a combination of routine measurement and accurate root-cause analysis,” she said. “You define the problem at hand with the right conceptual framework and then address [it] with concrete solutions, rather than the hand-waving that occurs that sort of inadvertently blames the population that we are talking about.”
With the hand-waving and racial assumptions that often dominate conversations around health equity come the inevitable questions of cost. Can providers justify expenditure on solving social problems?
With skyrocketing healthcare costs, providers can’t afford not to tackle social determinants of health, said Cleveland Clinic’s Myers.
“About 51% of the federal budget is a combination of social security and healthcare,” he said. “It’s one of the largest growing costs for all businesses. It’s simply not a sustainable curve.”
A great deal of time, energy and money go toward figuring out how to engage people and break down hurdles because the healthcare system does not have the necessary structures in place, AMA’s Maybank said.
But efforts to put those structures in place are not consistent and often disappear once the crisis of the moment has ended.
“We know folks are going to need interpretation and translation [services], we know folks are going to need transportation,” she said. “However, we just kind of revert back to the fragmented siloed healthcare system once [a] crisis is over…We waste a lot of money.”
Payers taking innovative approaches to reduce care gaps
Providers aren’t the only ones taking a harder look at their efforts to improve care for minority populations. Payers, too, are assessing their approaches.
For Hartford, Connecticut-based Aetna, data has been a game-changer, allowing the insurer to drill down into the individual needs of its members, said R.J. Briscione, senior director, social determinants of health strategy and execution at CVS Health Aetna, during INVEST.
The payer has partnered with social determinants of health startup Socially Determined to identify members with rising social risk; that is, patients who are likely to need high-cost healthcare if their social needs aren’t met.
The startup provides Aetna with seven different categories of social risk, including food insecurity, housing and health literacy, so that the insurer can customize its efforts and outreach, Briscione said.
For example, if Aetna identifies a pre-diabetic but doesn’t know whether they have health literacy issues, then providing the patient with apps or care management resources may not help. The payer is essentially flying blind with regard to what type of intervention would be most effective. Information provided by Socially Determined helps fill in those gaps and informs Aetna’s strategy.
Another focus for Aetna is ensuring equitable vaccine distribution.
“…this is where the genius of having a CVS combined with an Aetna comes into play,” Briscione said.
There have been concerns of vaccines not reaching the people most threatened by the Covid-19 pandemic — namely BIPOC and low-income communities. CVS is reserving appointments for these populations and filling them with Aetna’s help.
The payer has teams on the ground, servicing Medicare, Medicaid and dual-eligible members, with connections to community-based organizations.
“Our folks who have those relationships are sending the information on how to register for these equity appointments to those trusted organizations…and giving [them] time to get that information out to their membership,” Briscione said.
Facing a higher risk of illness during the Covid-19 crisis, as well as bearing the brunt of the economic regression has left the mental health of underserved populations in tatters.
This is why Louisville, Kentucky-based Humana has been focusing on alleviating loneliness — a particularly intractable issue amid a pandemic that necessitated social isolation, said Tray Cockerell, director of population health and health equity at Humana, in a phone interview.
Older adults have especially suffered, with 56% of people over the age of 50 saying they sometimes or often felt isolated from others in a survey conducted last June.
To help combat this, Humana collaborated with Papa, a Miami, Florida-based program that links older adults and families with “Papa Pals” for companionship and assistance with everyday tasks. Anyone can apply to become a Papa Pal.
Humana provided Papa with a list of its members who were screened for loneliness and matched them with people, mostly students, to provide a respite from the isolation, Cockerell said. The payer plans to expand this program over the coming year.
Payers are investing heavily in various programs to mitigate care gaps, but regaining trust will also require some out-of-the-box thinking.
“Trust is the most challenging aspect, specifically trust in the system,” Cockerell said. “That lack of trust was exacerbated by so many things in the last year.”
One of the ways in which Humana is working to build a bridge between the healthcare industry and minority communities is through education.
The insurer partnered with the University of Houston to launch an institute in 2019 within the latter’s college of medicine. Part of the vision for the institute is to bring in more first-generation medical students from underserved and minority populations, Cockerell said. Research shows that a majority of racial and ethnic minorities think it’s important to have a healthcare provider who shares or understands their culture.
The gaping health inequities that exist in American society today were not created overnight. Nor can they be tackled overnight. Real progress in this area will require healthcare stakeholders to take an unflinching look at the racism embedded in the system and acknowledge that answers may well exist beyond their walls. Addressing these inequities will require a wholesale culture change so it remains to be seen if entrenched players can move the needle toward a more equal healthcare system regardless of race and/or income level.
Photo: Angelina Bambina, Getty Images