In July 2021, the nonprofit Institute for Healthcare Improvement surveyed more than 500 healthcare professionals to better understand attitudes and perceptions surrounding health equity work. In a wide-ranging interview with Healthcare Innovation, IHI President and CEO Kedar Mate, M.D., discussed some of the findings about challenges health systems face gathering actionable data and implementing equity initiatives.
One of the most notable findings in the IHI Pulse Report is that the number of respondents who said that health equity is a top priority for their organizations jumped to 58 percent from only 25 percent in 2019. I asked Mate if he thought that was largely attributable to the movement that grew out of George Floyd’s murder last year or whether it was a trend that has been growing independent of that movement.
“I think it was building before the Floyd murder and subsequent racial justice rallies that we saw in the summer last year,” Mate said, adding that for the past five to seven years, equity has become a bigger factor in the healthcare landscape. “At the same time, the Floyd murder and the subsequent racial justice movements really accelerated health system leadership's interest in health equity.”
For health systems where equity is not a top priority yet, some respondents said their organization doesn't experience persistent disparities related to characteristics such as race, ethnicity and language. I asked Mate if this might reflect ignorance about the issues or denial about the seriousness of them.
He responded that in medicine people have a perception of fairness in the health system. “None of us believe that we're doing anyone harm. And sometimes when the data actually shows us the truth — that some harm is being done or some inequities are present — it's difficult for us to grapple with, because that goes against our perception of fairness and who we think we are.”
A similar thing happened with patient safety and patient harm information years ago, Mate noted. “Health system leaders had a perception that they weren't harming anyone. They were there to do good work for their people and for the patients. And all that was true. But we recognized with “To Err Is Human” and other subsequent reports that, in fact, there was a lot of harm happening in healthcare, and that there was quite a bit that we could do about it. Not only was that harm present, but the harm was modifiable.” He expressed hope that with health equity, we're going to go through that period of reckoning with the data and move toward an appreciation for the need to make improvements.
In the survey, executives reported myriad barriers to advancing health equity, with 38 percent citing inconsistent collection of equity-related patient data. The U.S. Government Accountability Office (GAO) just released a report that found that 47.2 percent of the COVID cases reported to the CDC had incomplete race and ethnicity data. I asked Mate if that give us a sense of the scope of the problem.
He said that from very early on in the pandemic, we lacked an understanding of who was being affected by COVID and later who was getting vaccinated. “We didn't have that data stratified by race, ethnicity, and otherwise, so we were substantially hampered in our understanding of what communities were most affected by COVID,” Mate said. “Of course, that started to change over the course of the pandemic, but even with attention to these issues, even with recognition of the disproportionate burden of COVID being borne by communities of color, we still have big data gaps that are present in our understanding of the pandemic. And that's true not just for COVID, but for everything. That's exactly what's represented in our poll, which describes the data challenges as one of the priority barriers to progress.”
Is it a data standards or EHR-related issue? Or is it more about incentivizing that data collection happen at the time of the patient encounter?
Mate said all of the above. “We need clear, standard approaches to how to stratify the data, and we need to set clear expectations that the data will be collected,” he added. “We need data collection standards that are uniform and consistent across care settings. Incentives to collect the data are extremely important, because is it going to take effort for health systems or health plans to gather the information.”
Healthcare Innovation has written several stories about health systems creating new chief health equity officer positions. I asked Mate what types of resources and backing these executives need to succeed.
“I have two reactions to this,” he said. “One is that I think equity should be the responsibility of the chief executive of an organization. If the end result of that product of the health system is better health for the community it serves, then equity is a critical dimension of that end result and product, which is why I think the entire executive suite, especially the CEO, needs to own that goal,” he said. “The second thought is that I do think that chief equity officers need data to enable them to do the work around equity, and they need a team.”
He stressed that in a collaborative that IHI ran with eight health systems, they noticed that health systems that made the equity improvement activities part of their quality department or department of population health’s obligations and duties tended to be more successful than those that did not. “That’s because it comes down to there being an authorized group within the organization whose responsibility it became to take action to close the inequities that we're seeing,” he explained.
CMS Director Chiquita Brooks-LaSure and CMMI Director Liz Fowler have stressed that equity is going to be at the heart of their re-evaluation of value-based care models. I asked Mate if there are certain things he would like to see from them related to equity as they reconsider alternative payment models.
Noting that we haven't yet seen a clear indication of what CMS is planning, Mate said he would hope for greater standards and definitions around what to measure and how to measure it, including guidance to payer organizations to support delivery organizations to collect that information.
He also would like to see CMS support provider organizations to collectively reflect on the data that start to emerge as a result of the standard collection of that information, and then start to think through what steps they might take to start to create more equity in their care systems. “I think it would be very possible for the Innovation Center, in particular, to help identify specific better practices that might help with particular inequities that are commonly seen in the data,” he said.
Mate noted that traditionally value-based payment models have tended to discourage collaboration between healthcare organizations. “The opportunity in front of CMS right now is to reconsider how to structure incentives so that they support collaboration, rather than competition around health equity,” Mate said. Perhaps one way of doing that would be to create levels of achievement for the whole community, he explained, and if the entire group of providers gets to a certain level of remediating inequity, they can get escalating levels of potential reimbursement or incentive payments.
Another barrier survey respondents mentioned was the inability to demonstrate the impact of a health equity efforts. I asked Mate if some health systems were starting to measure the impact of closing care gaps on clinical outcomes.
He said we should start using the data to understand where care practice variation lies, and where the inequities concentrate. He pointed to a recent report on the Blue Cross Blue Shield of Massachusetts website in which they stratify their data for 50 HEDIS measures by race and ethnicity. “It gives us an early indication of where there are opportunities to improve in the BCBSM-covered population,” Mate said. “Once you've got the data, and you've got the information about disparities, you’ve got to do something about it. What we have found at IHI is that when you apply a disciplined approach to change management, systems will take actions and providers will take actions to actually change the circumstances and improve care performance.”
He gave another example from a health system in Minnesota that saw a big Black/White disparity in colorectal cancer screening. They interviewed Black patients in the community to learn what it would take to improve cancer screening rates, took a series of steps based on that qualitative information that they captured, and then redesigned their cancer screening program, and started administering their program differently. “They saw a 19-point reduction in the difference between Black and White, for cancer screening rates,” Mate said. “Also, by the way, it improved cancer screening rates for White folks, too. It improved care for everyone in the system, which is something that I think we're going to observe more and more as we do this kind of work on equity.”
I had seen Mate quoted recently as saying that health equity is not just the province of healthcare, but there should be meaningful connections to communities, and that we need to invest differently with how to connect with communities. I asked him to elaborate on that idea.
He gave an example of Rush University Medical Center, which worked with other health systems to create a coalition that invested together on the west side of Chicago, where there are significant economic challenges as well as health-related challenges.
“They’ve invested in what they call Westside United, which is a group of community partners and health system partners, who are defining together a set of community level goals — in this case, reducing a big life expectancy gap by half in the next decade,” Mate said. They're creating a set of initiatives that both the health systems and their community partners will take action on. “Instead of creating a whole bunch of siloed activities on various social determinants where the health system is talking tangentially to community partners and relationships, in this case you have a big-picture goal that everyone has agreed on.” They have a much greater chance actually achieving a population level impact than most of the things that we've done historically would potentially amount to, he said. “That's the kind of thing that I'm talking about when I talk about a different level of investment. Some of it is economic, but a lot of it is in how we listen to our communities, and how we work with them. And that's where the biggest difference really lies.”