Can community health centers improve research diversity?

By Christine Chang, manager, Deloitte Center for Health Solutions, Deloitte Services, LP

Community Health Centers (health centers) provide comprehensive primary care services to medically underserved populations throughout the country. There are more than 1,500 of them in the US, serving about 1 out of every 10 people (32.5 million people)¹ and their patients represent a wide range of ethnicities, geographies, incomes, and races. Given their reach, and the diverse populations they serve, health centers could help improve diversity in clinical trials and other health research.

Nearly 90% of health centers are either participating in clinical research or are interested in doing so, according to a survey of 226 health center CEOs or their designees, conducted by the Deloitte Center for Health Solutions and the National Association of Community Health Centers (NACHC). However, 81% of respondents said they do not have dedicated staff to perform research, and 88% do not have budget or resources dedicated to research (see our report, Broadening research participation through community engagement).

Health centers “represent America,” Kyu Rhee, MD, MPP, president and CEO of NACHC, explained during a recent phone conversation. During our call, we covered a wide range of topics, including the role health centers can play in advancing more equitable and inclusive research. Here is an excerpt from that conversation:

Christine: Underserved populations have historically not participated in medical research (with their informed consent) due to a lack of awareness, lack of access, and mistrust (see Increasing clinical trial diversity). Excluding diverse populations from research can exacerbate existing health disparities, which cost the US about $320 billion per year (see The economic cost of health disparities). Why else do you think it is important to include diverse participants in research?

Dr. Rhee: Before joining NACHC, I was director of the office of innovation and program coordination at the National Institutes of Health, which is the largest public funder of biomedical and behavioral research institution on the planet with about $45 billion in funding.² I was focused on identifying and reducing health disparities. At the time, about 5% of all clinical trials had diverse participants. Now juxtapose that with the overall US population, which is about 40% [under-represented populations]. If you are doing research that builds solutions to serve the population, that research should reflect the population you are trying to serve. Research needs to address not just racial and ethnic diversity, but also gender diversity, geographic diversity, and socio-economic diversity. About 38 million Americans live at or below the federal poverty level.³ Not including that part of the population, for example, is going to limit the scientific results because it is not truly representative of the population. The populations we serve should have as much access to research as anyone else. Why shouldn't the populations we serve have research literacy and know that they're contributing something of significance?

Christine: What are some ways that health centers can help researchers recruit more diverse patient populations? And how can researchers work with health centers?

Dr. Rhee: Health centers already collaborate with many types of organizations on research, particularly academic medical centers. However, these relationships can be strengthened. For over 60 years, health centers have established a level of trust among [under-represented] populations. Trust is important to advance research. If trust is not there, patients will probably not participate. We also understand our patients. For example, researchers may not be able to attract participants if the people designing the study are not in tune with the needs of the community and the needs of patients. We heard about a clinical trial for a diuretic [which increases the amount of water and salt expelled from the body as urine]. While some people signed up to participate, many of them had to spend an hour or more on public transportation to get home…after taking a diuretic. The trial sponsors didn’t understand why none of those participants returned. Researchers should evaluate the parameters of a study early, in partnership with health centers, and design it in a way that attracts and retains more diverse participants.

Christine: It seems that health centers often want to get involved in clinical research, but don’t. What do you see as some challenges and how do you overcome those?

Dr. Rhee: Nearly 90% of the health centers we surveyed are interested in participating in health research, but they often don’t have the time, funding, infrastructure, or expertise. At their core, health centers tend to deliver comprehensive, high-quality, integrated primary care to urban, suburban, rural, frontier, and island communities that are underserved. But most health centers have tight margins. Their staff tend to be extremely busy, and they often don't have the capacity to take on extra projects. They should have sufficient time to identify, recruit, and enroll the appropriate populations. Health centers should be valued from a resource perspective.

Christine: Given your experience, how do you think about research at health centers?

Dr. Rhee: Health research can be everything from pharmaceuticals to food as medicine to the role of health insurance to transportation. There are two frameworks I use regardless of the type of research. One is SEPP (science, education, practice and policy). While at NIH, when we were looking at ways to reduce or eliminate health disparities, we used the SEPP framework. The beauty of health centers is that they are at the center of this practice. If you want to build science, whether it's new science, or real-world evidence, you should partner with the largest primary care system in the nation, which is health centers.⁴ The other framework is partnerships. You have the patient at the center, then a provider/primary care doctor, a payer, a purchaser, a policymaker, and a producer, such as a pharmaceutical company, and pioneers. All of these partnerships play an important role.

Christine: After academic medical centers, health centers are most likely to partner with federal agencies to conduct research.⁵How do you think about these types of partnerships?

Dr. Rhee: Regulators and federal agencies can play a role. There is the Department of Health and Human Services, and agencies within HHS, like NIH, and the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration. But there are also agencies that are not directly related to health, like the Department of Housing and Urban Development, the Department of Education, and the Department of Labor. Health is broader than just health care. Health centers should think about the importance of partnering with all of these diverse organizations across the health ecosystem.

Christine: What role did health centers play during the COVID-19 pandemic?

Dr. Rhee: Health centers were well represented and played an important role, providing more than 22 million tests and 24 million vaccines.⁶ We provided a lot of funding to vaccinate the populations that tend to have worse disparities and were more likely to be affected by the virus. During the pandemic, health disparities got worse for the populations we serve, and the life expectancy declined. Health centers are also important for providing real-world evidence that can help inform and improve science. COVID was a reminder that the health of the populations we serve affects every population. Infectious disease doesn't know race, ethnicity, gender, or socio-economic status. It affects everyone.

Christine: Part of NACHC’s mission is to help every health center in the country become “the employer, provider, and partner of choice.” What does it mean to be a partner of choice?

Dr. Rhee: We are now a partner of choice for teaching, for example. It's called teaching health centers. Through legislation, 100 health centers are training the next generation of primary care clinicians.⁷ And there's funding for that. Similarly, health centers can and should also be research centers and research partners in addition to providing excellent care.

Conclusion

Health centers provide important primary care services to diverse and often underserved populations throughout the US. They are uniquely positioned to enhance the diversity of health research, which is crucial for addressing health disparities and improving health care outcomes. On August 2, the White House cited the accomplishments of health centers in a presidential proclamation.⁸

Despite the high interest in conducting research, significant challenges remain. Getting health centers to play a larger role in research, particularly clinical trials, will likely require policy transformation, investment in infrastructure, and fostering trusted collaborations with a shared mission. NACHC will continue discussing this, as well as many other topics, at the NACHC 2024 Community Health Institute (CHI) & Expo, which is being held in Atlanta beginning August 24.⁹

The executive’s participation in this article is 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.

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Endnotes:

^{1_{Community Health Centers Report Record Growth in Patients to 32.5 million, National Association of Community Health Centers, August 5, 2024}}

^{2_{Impact of NIH research, National Institutes of Health}}

^{3_{Poverty in the United States, US Census Bureau, September 12, 2023}}

^{4_{Funding Increase for Community Health Centers Clears Senate, NACHC Statement, March 8, 2024}}

^{5_{Community-based clinical trials, Deloitte Insights, November 13, 2023}}

^{6_{Community Health Centers: A Vital Resource for COVID-19 Vaccination in the Era of Commercialization, National Association of Community Health Centers, August 5, 2024}}

^{7_{American Association of Teaching Health Centers}}

^{8_{A Proclamation on National Health Center Week, The White House, August 2, 2024}}

^{9_{2024 Community Health Institute & Expo}}

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