Year in Review: Health Equity

Dec. 17, 2021
In a survey of 500 healthcare executives by the nonprofit Institute for Healthcare Improvement, the percentage of respondents who said that health equity is a top priority jumped to 58 percent from only 25 percent in 2019

Early in the year, Healthcare Innovation made “Getting Real About Health Equity” one of our Top 10 Trends for 2021, and industry activity on equity issues seemed to accelerate throughout the year as health systems sought to address disparities in outcomes and social factors impacting patient health. Here are a few highlights from our reporting:

California leads the way. In January, California Gov. Gavin Newsom’s proposed $227 billion budget for 2021-22 includes establishing an Office of Health Care Affordability and a system to better use health data to improve health outcomes and address health equity. California was the first state in the nation to implement a health equity metric as part of its Blueprint for a Safer Economy framework. The equity metric requires counties to demonstrate an improvement in COVID-19 test positivity rates in neighborhoods facing the most severe impacts. The budget proposed several other initiatives expressly addressing health inequities. For instance, as Medi-Cal and Covered California managed care plan contracts come up for renewal, the Newsom Administration will work to include a focus on health disparities and cultural and language competency through health plan contractual language with a framework similar to the Blueprint equity metric.

Other state-level efforts. The Colorado Office of eHealth Innovation and the eHealth Commission have refocused the state’s 2021 Health IT Roadmap through an equity lens and are elevating equity goals through diverse representation on the eHealth Commission as well as funding projects across Colorado that advance equity and whole-person health. Providers interviewed for the Roadmap refresh process shared that they want to treat their patients as whole persons but cannot access holistic information to quickly understand each patient’s health needs. The Roadmap report also identified challenges with broadband access and health information exchange participation in rural areas of the state.

In December, Mandy Cohen, M.D., announced she was stepping down from her position leading North Carolina’s Department of Health and Human Services after directing the agency’s launch of Medicaid managed care. Cohen, who helmed NCDHHS for five years, led the development of an approach to whole-person care, including the integration of physical and mental health and using Medicaid to address drivers of health such as housing, transportation, and employment. In addition, during her tenure, North Carolina implemented a statewide coordinated care network, NCCARE360, to electronically connect those with identified needs to community resources.

New direction from CMS. In an April 20 talk to the National Association of ACOs, Elizabeth Fowler, J.D., Ph.D., the new director of the Center for Medicare and Medicaid Innovation (CMMI), said the organization would be looking at its alternative payment models with a health equity lens. Fowler began her talk by noting that the pandemic has shown us how far we have to go by revealing some of our biggest shortcomings. “COVID exposed vast racial and ethnic disparities in the health system and the care it provides, and it also demonstrated the shortcomings of fee for service when volume drops precipitously,” she said.

Public health and health equity. The pandemic has highlighted many gaps in public health data gathering concerning race and ethnicity. In May 2021, the Robert Wood Johnson Foundation (RWJF) announced it was establishing a National Commission to Transform Public Health Data Systems, which is charged with re-imagining how data are collected, shared, and used, and identifying which public- and private-sector investments are needed to modernize public health data infrastructure to improve health equity.

Changing attitudes about equity. 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 an 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 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. Healthcare Innovation 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.”

Measuring inequity at the state level. In November the Commonwealth Fund published a new state-level scorecard on health equity data that paints a disturbing picture of disparities in health access and outcomes. The scorecard “exposes a range of deep-seated racial and ethnic healthcare inequities within all 50 states,” said David Blumenthal, M.D., president of the organization. “There's little doubt that the pandemic has exacerbated these inequities and other weaknesses in our healthcare system.” The scorecard report looks at 24 measures of performance stratified for five racial and ethnic groups including Black, Latino, Native, Asian and white Americans. The data timeframes in the report vary by indicator, but generally reflect 2019 and 2020. Health equity does not exist in any state, even those with stronger health systems, the report found. In every state, health system performance is markedly worse for many people of color when compared to white people.

CMS listening session on equity. Wrapping up the year, on Dec. 8, the CMS Innovation Center brought together health equity experts for a roundtable discussion on how federal policymakers can execute on their stated objective to advance health equity. During the discussion, Alice Chen, M.D., the chief medical officer at Covered California and formerly the deputy secretary for policy and planning and chief of clinical affairs at the California Health and Human Services Agency, said CMMI should focus on alignment, starting with the three M's of Medicare, Medicaid and Marketplace and invest in multi-payer models that are geographically focused, because particularly for vulnerable communities health happens locally, she said. Chen added that we also need to align on measurement. “There are just too many measures in play, and just too much variation across programs,” she said. “The sad truth is that healthcare providers are not equipped to improve on more than a few things at a time. We need a parsimonious set of measures — fewer than 10 — that are core across all the programs and tied to both key drivers of morbidity or mortality, and stratified and targeted for disparities reduction. I would say hypertension, diabetes, colorectal cancer screening are no-brainers across all these programs.”

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