Health inequity is a chronic condition

By Jay Bhatt, D.O., managing director of the Deloitte Health Equity Institute and the Deloitte Center for Health Solutions, Deloitte Services, LP

During a recent snowy Saturday in Chicago, I had the opportunity to moderate a panel on health equity at the annual Kellogg Business of Healthcare Conference at Northwestern University.

While it is typically discussed in terms of race and ethnicity, health equity is much broader. It can extend to gender, people who have disabilities, veterans, and the 20% of Americans who live in rural communities (see Advancing health equity through community-based ecosystems). Everyone, regardless of who they are or their circumstances, should have an opportunity to achieve their highest potential for health and well-being.

Health inequities are particularly apparent in kidney care, said Danelle Radney, director of health equity at DaVita, a kidney care company. She noted that about 99% of dialysis patients have access to health insurance.¹ But despite health coverage and support from social workers and dieticians, there are “huge inequities within the kidney care space,” she said. While Black Americans represent 13% of the US population, they make up more than 30% of the kidney disease population.²

Consider this: Over the past 20 years, the estimated Glomerular Filtration Rate (eGFR) has been widely used to determine kidney function. It combines a blood test with a patient’s characteristics (e.g., age, height, gender, weight, and race).³ The method has been shown to be inherently imprecise and biased because it assigns Black patients a significantly higher kidney function than white patients. This makes the kidneys of some Black patients appear healthier than they are, which can delay diagnoses and treatment. It can also negatively affect where patients are on organ transplant lists, according to the National Kidney Foundation.

Despite the algorithm’s proven bias, it can be difficult to convince some organizations to change. Derek J. Robinson, M.D., chief medical officer at Blue Cross and Blue Shield of Illinois (a Division of Health Care Service Corporation), recalled a March 2021 conversation he had with physician leaders at a national laboratory that still used the race-based modifier in lab reports to calculate kidney function. “The company tried to convince me—an African American practicing physician—that this race modifier was actually good for Black patients because doctors would be more likely to prescribe the diabetes medication Metformin to those with diabetes,” he said. “Systemic racism in health care is insidious and far reaching. We must have the courage to have difficult conversations and lead the change that is necessary. I have seen it happen and we should celebrate these successes.” ⁴

Can barriers to health equity be broken?

The panel raised questions about some of the systemic and structural barriers that may contribute to health inequities and offered thoughts on how those barriers might be removed. Here’s an overview of some of the topics we discussed:

• Data: Deloitte worked with a rural hospital that determined 22% of women with kidney disease were being readmitted versus just 12% of men. The hospital set a goal of getting readmission rates down to zero. Danelle suggested that kidney care might be a place to try to demonstrate that health equity can be achieved. The first step might be to collect data, interrogate it, and ask questions that explain the data.
• The drivers of health: The average life expectancy for a person without stable housing is 27.3 years less than someone who has stable housing⁵ (see Addressing the drivers of health). A recent survey found that people who cut back on utilities also cut back on medical care and health spending. And among people who skipped a meal, 71% also cut back on medications and health care.⁶ Health inequities can also be compounded by inflation, forcing some people to make tradeoffs that can negatively affect their health (see Inflation’s impact on health care). Health coverage is another driver of health, said Megan Simmons, director of policy at the National Birth Equity Collaborative. She explained that insurance is typically tied to where we work. People who have access to education tend to have access to better jobs, which gives them access to better health insurance, she explained. More than 2.2 million women of childbearing age live in maternity care deserts in the United States (1,095 counties) that have no hospital offering obstetric care, no birth center, and no obstetric provider. The Deloitte Health Equity Institute collaborated with the March of Dimes in the development of a Maternity Care Deserts Dashboard.)
• Virtual health: The vast majority of consumers say they would use virtual visits, according to a survey conducted by the Deloitte Center for Health Solutions (see Tapping virtual health’s potential). Kristin Myers, CEO of Hopscotch Health, noted that while as many as 80% of Americans have access to broad-band internet, the percentage might be less than 50% in some rural areas. “Ensuring we can deliver care to patients, where and when they need it most, is a priority to ensure there is access to care, especially in rural communities,” she said. “At Hopscotch Health, we are focused on bringing high-quality, tailored primary care to rural communities across the country. The broadband challenges mean we need to be even more creative about solutions that will work for our patients. This might mean setting up a dedicated room for telehealth in our clinics so that our patients can do a virtual visit with a specialist instead of driving 2+ hours” (see Advancing health through alternative sites of care).
• Lived experiences: Megan said her organization holds listening sessions where patients are asked targeted questions about their lived experience. An expectant mother, for example, might explain that a part-time job or childcare makes it difficult to make doctor appointments. A patient might not make an appointment because they are uncomfortable talking with a doctor who doesn’t speak their native language. Understanding the lived experience can help serve those patients better. She said listening sessions are highly informative but suggested that organizations conducting them consider paying participants for their time.

Health equity is everyone’s business

The cost of health inequities is $320 billion today, which could more than triple to $1 trillion by 2040 if no changes are made (see our report on the Economic cost of health disparities). Danelle said the private sector has a responsibility to look for ways to improve health equity. “Health equity should be integrated into the fabric of how we do health care,” she said.

Over the past year, the Deloitte Health Equity Institute (DHEI) has launched numerous cross-sector collaborations to help advance health equity. An article in the latest issue of the Journal of Health Care for the Poor and Underserved, highlights a collaborative effort between the DHEI, CommonSpirit Health, and Get Well that helped boost COVID-19 vaccination rates in two geographically distinct locations (see Multi-sector collaboration leads to successful vaccination-outreach program). Early this year at the World Economic Forum’s Annual meeting in Davos, Switzerland, Deloitte Global joined 38 other organizations in signing the Global Health Equity Network Zero Health Gaps Pledge. The Pledge is a commitment to help advance health equity and support better health outcomes. Participants included a wide range of companies from the private sector.

Health inequity is a chronic condition in the US. As organizations work to try to make health more equitable, they should consider the following steps…and questions:

1. Be intentional—Can products or services be created or enhanced to improve the ability to detect diseases earlier or prevent them altogether?
2. Form cross-sector partnerships—What new capabilities can be gained (and which existing capabilities can be enhanced) by developing relationships with other organizations?
3. Measure progress—What data does the organization require to understand the disparities of the population being served?
4. Address individual and community-level barriers—Does the organization understand the unique needs of the communities and people they serve?
5. Build trust—Does the organization understand the perspective of the communities and people they serve?

Kristin told attendees that achieving health equity seems like an insurmountable challenge, but added that “many small steps, over time, in the right direction, can eventually turn into huge leaps.”

Endnotes:

¹ Insurance and costs for dialysis, American Kidney Fund 

² Race, ethnicity, and kidney disease, National Institute of Diabetes and Digestive and Kidney Diseases

³ Removing race from estimates of kidney function, National Kidney Foundation, March 9, 2021

⁴ Chronic Kidney Disease: Examining Health Disparities in Communities of Color, Blue Cross and Blue Shield of Illinois, June 24, 2022;  Rethinking race modifiers, Blue Review, September 21, 2021

⁵ Housing and health: A roadmap for the future, the American Hospital Association, March 2021

⁶ Higher bills are leading Americans to delay medical care, The New York Times, February 16, 2023

Latest news from @DeloitteHealth

The individuals’ participation in this article are solely for educational purposes based on their knowledge of the subject and the views expressed by them are solely their own. This article should not be deemed or construed to be for the purpose of soliciting business for any of the companies mentioned, nor does Deloitte advocate or endorse the services or products provided by these companies.

This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor.

Deloitte shall not be responsible for any loss sustained by any person who relies on this publication.

Return to the Health Forward home page to discover more insights from our leaders.