By JUDITH VANDEWATER
BOSTON — There has always been a strong ethical case for eliminating race-based disparities in health access, treatments and outcomes. Now, a compelling and even urgent business case can be made as well.
That was one of the central themes of the first Healthcare Quality and Equity Action Forum held in Boston in late September and presented by the Disparities Solutions Center at Massachusetts General Hospital. The center is attempting to build a national advocacy initiative to keep health equity at the forefront of health reform.
Minorities make up more than one-third of the U.S. population; and, according to the U.S. Census Bureau, by 2023, more than half of all children will be members of minority groups. Speakers at the two-day meeting said reducing or eliminating race-based disparities is essential to improving the health status of communities and containing rising health care costs — twin goals of health reform.
Dr. Joseph R. Betancourt, founding director of the six-year-old Disparities Solutions Center, said the restructuring of the health care financing and delivery systems under way now make this an opportune moment to press the cause of health equity.
Chief executives of Catholic Health Initiatives of Englewood, Colo., and CHRISTUS Health of Irving, Texas, are among ministry leaders who have made health equity mission and strategic priorities in their systems, and both systems sent senior executives to the forum.
The door cracks open
Research shows multiple factors contribute to disparities in health care access and outcomes. Among them are the patients' education level, socioeconomic status, health literacy, English proficiency and communication skills. Lack of access to primary care and specialty providers contribute to health disparity, as does provider bias and stereotyping, and the level of trust between patients and providers.
Just as there is no one source of the problem, there is no one solution. The fixes won't be simple, Betancourt said. But health reform presents much opportunity to make progress. "As we move toward accountable care organizations, patient-centered medical homes, value-based purchasing and compensation for patient experience and financial disincentives for (hospital) readmissions — every one of these areas holds opportunity for us," Betancourt said.
Admittedly, there has been fitful progress in addressing health disparities since the Institute of Medicine's 2002 clarion report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care." The IOM report established that even when insurance, income, age and severity of conditions are held constant, members of racial and ethnic minorities in the U.S. are less likely than whites to receive evidence-based medical care and life-extending procedures such as bypass surgery and kidney dialysis or transplants. Members of minorities also are more likely to endure lower limb amputations as a consequence of diabetes or other conditions.
Health systems quality expert Dr. Donald Berwick framed the issue this way during a video interview aired as a session opener: "Right now the biggest predictor of life expectancy in the U.S. is your race."
Where people live is also important. Brian Smedley, the lead editor on the IOM disparities report, told conferees that in some U.S. communities there is a 20- to 30-year difference in life expectancy between residents of different zip codes. "We don't need to tolerate the kinds of inequities we see in our work measuring health status," he said.
Betancourt told the audience of about 150 physicians, health system executives, health navigators, public health practitioners, regulators and insurers that research connects some of the root causes of health care disparity to every single aspect of quality and safety. For example, minorities and people with low English proficiency — not unlike people of low literacy — are at greater risk from medical errors that carry clinical consequences and costs, he said.
High-cost neglect
The Joint Center for Political and Economic Studies concluded in a report covering health expenditures from 2003-2006 that 30 percent of direct medical costs faced by African Americans, Hispanics and Asian Americans were excess costs due to health inequalities.
Low-income minorities often have a challenge accessing timely care, in part because of the lack of health services in their neighborhoods. Delays in care can exacerbate chronic health problems and increase lengths of hospital stays. Betancourt cited research showing that minorities with congestive heart failure are more likely to be readmitted to a hospital within 30 days of release than white patients, and they have longer hospital stays.
Betancourt said the link between health spending, quality and safety is key to getting buy-in from health care leaders and public policy makers for efforts to reduce health disparities.
Risk management
Dr. Thomas H. Lee, chief executive of Partners Community Healthcare, said that as health care providers accept more risk-based reimbursement contracts from government and private payers, the health providers' success will be pinned to the health of their patient populations. He said it is not possible to "cherry pick" only healthy patients under these arrangements. To create the large populations of patients that are necessary for actuarially sound risk-sharing insurance contracts, the gates must be opened wide. Providers, he said, must find ways to improve care to members of historically medically marginalized groups, including the poor and minorities.
The Patient Protection and Affordable Care Act subsidies will result in up to 17 million more low-income people signing up for Medicaid coverage in 2014. That historic expansion makes this a moment in which "our idealistic opportunities and our pragmatic imperatives just might be converging," Lee said. "People running delivery systems really understand that things have to change."
Smedley said Medicaid expansion has important implications for communities of color and for health facilities planners. About half of those who will be able to newly enroll in Medicaid in 2014 are in poor communities, places where people may be sicker and where health resources do not match need. Smedley said the Affordable Care Act provides incentives to expand community health centers and bring other health services to medically underserved areas. He directs the Washington, D.C.-based nonprofit Health Policy Institute for health equity, an affiliate of the Joint Center for Political and Economic Studies.
Smedley said there are about 75 provisions in the Affordable Care Act related to reducing health disparities, some by virtue of their potential to advance care quality for all. Among those provisions is a requirement that health providers collect in a standardized way information on patients' race, ethnicity and preferred language. "Data collection is going to be enormously important to allow us to measure access and quality as well as patient outcomes" and to pinpoint when and where disparities in care occur in order to target improvements there, Smedley said.
The law requires nonprofit health care systems to conduct community needs assessments in collaboration with other community agencies. The results will make hospitals better able to fine-tune programming and encourage public investments that promote health, including safer streets, good housing and adequate transportation to jobs. "We have to attend to social determinants of health," Smedley said. "In many cases clinicians are dealing with the backside of broader inequality in our society. Addressing social, economic and environmental conditions is going to be important."
Get moving
The vision for a health equity tool kit that emerged at the Boston conference includes the use of home medical monitor equipment to track the progress of recently discharged hospital patients. It also includes tactics that take advantage of the fact that the majority of minorities and immigrants own cell phones.
Dr. Kamal Jethwani told the audience that cell phones and computers have great potential as tools to reach and teach vulnerable populations. Immigrants are especially adept at using video-sharing software to link to distant family members; that aptitude holds promise for improving communications with medical providers. Even at the lowest income levels, 50 percent of adults use the Internet, Jethwani said. He is manager of research and innovation for the Center for Connected Health at Partners HealthCare.
Jethwani and Dr. Lenny Lopez of the Disparities Solutions Center are piloting a texting software program that encourages diabetic patients to exercise and lose weight. Patients who need a push get messages suggesting they buy athletic shoes. Those who are exercising can use pedometers that transmit daily exercise reports to a computer program that responds with praise or promptings. "It hones in on what the patient is thinking," Jethwani said. A fair weather walker might get a message saying, "It is going to rain tomorrow. We've seen your activity drop while it rains. Why not run five minutes? It's equal to 10 minutes of walking."
Copyright © 2012 by the Catholic Health Association of the United States
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