Population Health? Slash Health Disparities First

For an industry that is transitioning to population-based healthcare, reducing health disparities is essential for achieving the triple aim of better cost, quality, and outcomes.

Despite a landmark report published by the Institute of Medicine more than 10 years ago, Unequal Treatment: Confronting Racial/Ethnic Disparities in Health Care, which highlighted the effects of racial and ethnic healthcare disparities in the U.S., there has been little progress in improving health outcomes equitably.

According to the CDC's 2013 report on disparities and inequalities in healthcare, there were many disturbing trends that showed a disproportionate share of poor health outcomes for basically anyone who is not white. Out of all the statistics, I picked the one that I thought would get most healthcare executives to sit up and take notice: preventable hospital readmissions. From 2001–2009, the rates of preventable hospital visits were higher for non-Hispanic blacks and Hispanics when compared with those of non-Hispanic whites.

For an industry that is transitioning to population-based healthcare, reducing health disparities is an issue that not only deserves attention, but is essential for achieving the triple aim of better cost, quality, and outcomes.

"It's the issue no one really wants to discuss, says Frank Astor, MD, MBA, FACS, chief medical officer of Naples, FL–based NCH Healthcare System, which includes two hospitals and more than 500 affiliated physicians. "It's very complex, but it is essential if we're going to do holistic population health." Prior to joining NCH, Astor was the medical director for Blue Cross Blue Shield Puerto Rico.

Equal or Equitable?
One issue that holds physicians back is understanding the difference between providing equal care and equitable care. The distinction is not just semantics, explains Marcus McKinney, MD, D.Min, vice president of Community Health Equity and Health Policy at Saint Frances Care, a Hartford, Connecticut–based integrated health system that includes three hospitals, more than 900 affiliated doctors, and community clinics.

"We constantly hear, 'We treat everyone equally!'" says McKinney. "But if you treat every single human being equally, you're not giving equitable care to someone who has no job, for example. If a patient is diabetic and has a family history of diabetes, a doctor will take that into account. We have to do the same thing for social determinants."

Treating patients equitably means understanding what patients' needs are in order to get an outcome that is equal. For the patient with no job that McKinney references, it means developing a care plan that positions that patient to get the same outcome as the patient who is employed.

McKinney understands the concept well because Saint Francis Care has been at the forefront of reducing health disparities in its community. The system began focusing on the issue six years ago, and has since developed the Curtis D. Robinson Center for Health Equity, a program that has eight full-time employees and is housed within the Urban League of Greater Hartford.

"We know that what drives two-thirds of our underserved patients is social determinants," says McKinney. "Our strategic plan has to look under the hood and see that we're making a difference."

Disparities Leadership Training
McKinney will get a big boost to his vision. He is one of two physicians at Saint Francis Care that was selected to join the Disparities Leadership Program, a year-long executive program at the Boston–based Disparities Solution Center at Massachusetts General Hospital. The other physician joining McKinney is Luis Diez-Morales, MD, medical director for both the Curtis D. Robinson Center for Health Equity and ambulatory care at Saint Francis Care.

"There has to be more education on equality versus equity," says Diez-Morales. "Some [physicians] have a problem with the idea that equality is not the same as equity. I have seen a few light bulbs go on, and some go out."

The program that McKinney and Diez-Morales were selected for is in its eighth year, and Aswita Tan-McGrory, deputy director of the center, says this year's class is the largest ever.

"We have 60 participants," she says. "We have a huge alumni base—121 organizations, 252 participants. Our program is focused on helping executives achieve equity in their organization. People know it's the right thing to do, but don't have the right tools. We provide content expertise and a framework for organizations to move this forward."

Executives who are chosen for the Disparities Leadership Program are put in groups ranging in size to work on projects that the participating organizations have chosen. The structure of the program is virtual and in-person. Throughout the year, the participants meet with peers and are assigned a facilitator.

"Part our structure is giving hands-on access to faculty members and peer support," says Tan-McGrory. "This is more than learning about disparities, it's also about how to sell this to leadership in an elevator pitch."

McKinney and Diez-Morales are working on a project that integrates health equity across Saint Francis Care, beyond the Curtis D. Robinson Center for Health Disparities. Diez-Morales says the center gave the system a solid foundation, but now it needs to be hardwired in other parts of Saint Francis Care. Their project will focus on the system's large hospital-based primary care clinic that sees 80,000 patients annually.

"We have to start with our own staff," says Diez-Morales. "There are about 35 total healthcare providers working there, and we have between 40–50 residents who rotate with us throughout the year."

A Matter of Trust
What Diez-Morales and McKinney already know is that identifying the needs of patients comes first. A successful prostate screening initiative started six years ago put them in front of black men, a group of patients that the CDC report identified as being at risk for missing important medical screenings, diabetes, preventable hospitalizations, and other diseases. The two physicians have gone to churches and even barbershops in Hartford to hear patients' concerns about getting screened and seeing a doctor, generally.

"Forty men all jumped into talking about how complicated it is to talk to doctors," says McKinney. "They want it to be simpler. We try to simplify it in the form of a relationship."

The doctors also said it was clear that the men didn't trust their PCPs.

"The majority of men who came [for screening] had a primary care provider, had a relationship with a physician, but they felt something was lacking," says Diez-Morales. "It's very eye-opening to hear a patient say, 'I have a doctor, but I don't know if I trust that doctor.' "

That prostate screening initiative reached more than 7,000 patients; 40 were diagnosed with prostate cancer. That screening program still continues today; McKinney and Diez-Morales are still going to churches and barbershops, making inroads with the community because it takes a long-term commitment to establish trust and break down barriers that prevent patients from getting healthier.

"We have to be teachable," says McKinney.

"A physician who has been entrusted for 10, 20, 30 years doesn't like to hear that the way he or she has been doing it needs to be changed. That is the resistance we find, and we need dedicated attention to that. The statistics are not getting better for population health."