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October 5, 2016
In the introduction to its new white paper, Achieving Health Equity: A Guide for Health Care Organizations, the Institute for Healthcare Improvement (IHI) tells the story of Tommy Cannon, a black American with type 2 diabetes and no access to preventive healthcare, who died in 1973 at the age of 62. Cannon waited hours in a segregated physician’s office. When the physician finally saw him, he told him to go to a hospital 50 miles away because he was so ill. He died the next day from sepsis due to a ruptured appendix without ever being treated by a physician.
Although the healthcare system’s failure to give Cannon the care he needed took place decades ago, healthcare providers still have a lot of work ahead of them to make health equity a reality in the United States, according to the white paper. Despite some improvements, for example, life expectancy for black Americans in 2010 was equal to that of white Americans in 1980.1 Cannon’s life “mirrors the current state of millions of people in the U.S. who continue to struggle with connecting to the healthcare system, often resulting in poor health, development of chronic disease, and, for some, preventable death,” the authors write.
The IHI publication provides a framework to help healthcare organizations tackle disparities related to race, ethnicity, religion, income, sexual orientation and a host of other factors, emphasizing the business as well as moral reasons for doing so. Poorer health outcomes within marginalized populations increase costs for health systems, insurers, employers and families, according to the paper. Although “healthcare organizations alone do not have the power to improve all of the multiple determinants of health for all of society, they do have the power to address disparities directly at the point of care,” write the authors.
The framework presented in the white paper is based on five core ideas:2
Make health equity a strategic priority. Healthcare leaders must clearly articulate health equity’s significance as a priority for the organization. Goals to reduce health disparities should be woven into the organization’s strategic business plan, with the importance of health equity gains elevated from “nice-to-haves” to “must haves.” Some organizations build incentives based on reductions in health disparities into executive compensation plans.
Providers should explore the potential of new payment models, such as accountable care organizations and bundled payment plans, to support improvements in health equity. Incentives for reducing health disparities are integral to these value-based payment models. “As providers assume more financial risk for populations, improving health equity will make more financial sense,” according to the paper.
Develop a structure and processes to support health equity work. Healthcare organizations need a clear leader and governance structure to give health equity the visibility and prominence it requires. This structure should begin with the creation of a governance committee to oversee and manage equity work across the organization. Henry Ford Health System, for example, has a wellness and diversity officer who ensures that departments and staff have the resources they need to carry out health equity projects. HFHS will soon establish a Center for Healthcare Equity.
Providers should allocate sufficient resources in the budget for equity work as well. Robert Wood Johnson University Hospital, for example, provides resources for health equity activities to seven Business Resource Groups (BRGs) across the organization. Five percent of hospital employees participate in these groups, and each BRG has an executive sponsor.
Deploy specific strategies to address the multiple determinants of health on which healthcare organizations can have a direct impact. These determinants include healthcare services, socioeconomic status, physical environment and healthy behaviors.
To develop healthcare services that reduce health disparities, organizations should first collect and analyze data on race, ethnicity and language (REAL) to understand where the disparities exist. An analysis of data by HealthPartners in Minnesota identified disparities in mammography and colonoscopy rates based on race and insurance coverage. The system implemented improvements to close the gaps.
Organizations should make sure their quality improvement efforts meet the needs of marginalized populations. Focusing on results for the entire population can obscure the fact that disparities are actually growing within subpopulations. For example, differences in mortality rates between black and white individuals in the U.S. due to heart disease, breast cancer and stroke actually increased between 1990-2005 despite gains in the population as a whole.3 The IHI recommends focusing first on the populations with the worst health outcomes. In many instances, this approach also can lead to better care for the overall population.
As major employers and economic “anchors” in their communities, hospitals and health systems can address health equity by working to improve the socioeconomic status of their own employees. One strategy is to focus on service delivery improvements that eliminate waste, emphasize preventive care and reduce costs. Organizations can then transfer the savings back to employees in increased wages.
The IHI also encourages providers to:
- • Procure supplies and services from women- and minority-owned businesses.
- • Build healthcare facilities in underserved communities.
- • Work to reduce medical waste and pollution, and support the creation of community spaces, parks and walking trails.
- • Support healthy behaviors among employees by offering activities and programs such as healthcare coaching and annual health risk appraisals. Decrease institutional racism within the organization. Healthcare organizations should look closely at their contributions to institutionalized racism, defined as “differential access to the goods, services and opportunities of society by race.” According to the paper, “Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage. It is structural, having been codified in our institutions of custom, practice and law.”
Some health facilities are built with the needs of patients who generate the most revenue in mind rather than with consideration for the most pressing community health needs. The types of health plans accepted by organizations also can perpetuate health disparities by limiting access to services by low-income individuals. Efforts to “improve the patient or payer mix” can be code for denying care to Medicaid patients because this program reimburses at a lower rate. Providers should consider health disparities as well as financial performance in contracting with insurance plans.
The IHI urges healthcare organizations to work to reduce implicit (unconscious) bias within the organization’s policies, structures and norms through education and training programs; and to implement strategies to raise consciousness among clinicians and help them reshape their responses.
“Implicit bias may affect how providers and other clinicians interact with patients in terms of communication, treatment protocols or recommended treatment options, or options for pain management,” the paper states. One study, for example, found false beliefs about biological differences between white and black patients among a significant number of medical students and residents, such as the belief that black skin is “tougher” than white skin.4
Develop partnerships with community organizations to work together on community issues related to improving health and health equity. Rather than reinvent the wheel, healthcare organizations can partner formally or informally with existing community organizations that already have programs in place to meet the needs of marginalized populations. The Health Improvement Partnership of Santa Cruz County, California, for example, a coalition of 26 organizations, has developed a program for infants insured by Medicaid to decrease emergency room utilization during the first year of life by connecting mothers with primary care services.
“Health equity is not a fourth aim, but rather an element of all three components of the Triple Aim” of improving the individual experience of care, improving the health of populations and reducing the costs of care, the authors conclude. “The Triple Aim will not be achieved until it is achieved for all.”
1Wyatt R., Laderman M., Botwinick L., Mate K., Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute forHealthcare Improvement; 2016, p. 6.
4Ibid, p. 22.