Health equity

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Heidi: Health care is a basic human right; however, racism and bias, deep inequities, and structural flaws in the health system in the US have led to quantifiable differences in health outcomes.

This is Tales of Transformation. Today, we are addressing health equity and force multipliers of the moral, economic, social, and environmental imperatives that require business solutions.

I’d like to welcome Dr. Kulleni Gebreyes, US Consulting Health Sector Leader, Director of the Health Equity Institute, Deloitte Consulting, LLP; Courtney Christian, Senior Director of Policy and Research, PhRMA, the Trade Association; and Dr. Sherita Hill Golden, Vice President, Chief Diversity Officer, Johns Hopkins Medicine. Welcome.

Dr. Golden: Thank you for having us.

Dr. Kulleni: Thank you.

Courtney: Thank you so much for having us.

Heidi: Each of you work in a different area of life sciences and health care. Courtney, let’s start with you. Can you share with us how health disparities show up in each of your worlds, and what business issues are at the forefront for each of you?

Courtney: Thank you so much for that question. It’s one that the bio-pharmaceutical industry has been answering in various ways and continues to work toward. We believe strongly that diversity and equity inclusion are essential to the discovery of new medicines and also for access to treatment for people of all ethnic and racial backgrounds. So that really means for us as an industry taking a more active role, as well as supporting public policies that address health disparities and working together with the broader health care ecosystems to create a more just and equitable health care system for everyone. So we’re committed to working with everyone, improving access to medicines, improving affordability of medicines, and improving data to measure inequity. We start by recognizing the social determinants of health that are central to improving equity and health outcomes.

So we know that racially diverse and other underserved populations are diagnosed and treated for disease later, they’re less likely to be prescribed and receive more innovative medicines, and also may have higher rates of non- adherence. So we know that poor access is a symptom of inequity along that continuum of care. As part of our efforts on health equity, we want to tackle solutions around affordability of medicines.

Our industry provides many discounts and rebates. They’re often not passed along at the pharmacy counter. So we really want to lean into the source of policies that allow that rebate pass-through but also reduce disparities as a downstream effect.

And then third, we heard so much throughout this pandemic about the significant gaps in collection of race and ethnicity data that contributed in part to inequities in testing and the distribution of vaccines and therapeutics. We can’t measure what we don’t know. How do we do better around data collection? Collecting data in an ethical manner and in a legal manner, but also doing more to collect data that helps inform how we could do better in changing the trajectory of health outcomes.

Heidi: Courtney, as a follow-up in terms of better data collection, what are the ways in which you’re looking at creating best practices for engagement with community?

Courtney: We established last year the PhRMA Collaborative Action to Reach Equity grant. What we’re trying to do there is ask seminal questions around the three priorities that I laid out and solicit ideas, RFPs, to community organizations, national organizations, HPPUs, the people who are working on issues around disparity, define community level best practices that are working on the ground and those that could be scaled up to be held up as a national model. We are finding a lot of really innovative ways that folks are approaching some of the long-standing issues in their communities, but also how they’re leaning in to really be part of solution making.

Heidi: Thinking about the provider and plan, Dr. Golden, what do you see in terms of some of the business issues that are at the forefront?

Dr. Golden: How has the health care system contributed to the inequities and then understanding how can we be a part of the solution? Access to care is one of those things, one of the five areas of the social determinants of health that we think about, but I think it’s important to step back upstream even further and think about, what are the factors that contribute to whether or not someone even has access to care?

So our former policies in the country around housing, there was discrimination against lending federal loans for homes to not only Blacks in America, but Jews, immigrants, Hispanic individuals, and Asian individuals in the country.

We know that home ownership is an important part of economic empowerment. Good jobs that contribute to the ability to have strong health insurance coverage impacts access to health care.

So, for example, when the New Deal legislation was put in place, farm and domestic laborers were excluded from getting Social Security benefits. The populations who were farm and domestic laborers, many of them were Black and brown members of our community.

Those things have really been critical in leading to things like racial residential segregation, where you have people living in neighborhoods where there’s not a lot of sidewalks and green spaces to engage in physical activity, and food deserts or food swamps where they don’t have access to healthy food choices, and all of those things impact their health. And then many minoritized communities experience bias within the health care system and then historically have been marginalized and experimented upon without their consent. And that’s led to a violation of trust. So these are all of the things that we have to understand as upstream factors contributing to disparities.

So how do we translate that into solutions? As we’re thinking about redesigning health care delivery, then we need to think about making sure that we’re not only giving people access to health care in the health system but making sure that we’re redesigning our communities to address the issues that patients are living with that impact their ability to take care of their health adequately. So then that leads to the second component, which is the importance of being advocates so that we can actually change legislature and address policies that are reinforcing structural racism. The third part is ensuring that we’re implementing the culturally and linguistically appropriate standards for health care delivery. So those were put out by the Office of Minority Health in the early 2000s. The idea with the class standards is that you’re ensuring that you are delivering care that is culturally appropriate in a patient’s given language, at their appropriate literacy level, ensuring that you’re also collecting the demographic data that Courtney just alluded to so that you can assess whether or not you still have disparities and then readapt your interventions, if you are experiencing them, to deliver equitable care. And then, of course, the fourth component is ensuring that we have biomedical workforce diversity, so not just our physician workforce, but every component of our biomedical workforce.

And in many cases that is now going to involve not just taking care of patients inside of our brick and mortar, but actually taking care to them in community-based settings. So it’s really re-engineering and really thinking about how we redesign care to overcome some of the barriers created by the social determinants of health.

Heidi: For me a lot of these conversations are health is where you are. By the time you have a person in hospital, it’s much harder. Dr. Gebreyes, director of the Health Equity Institute, how are you approaching health disparities in your world and the business issues?

Dr. Gebreyes: As I reflect on how health equity and how health care disparities show up in the world of professional services and consulting, the work we’ve done has actually said, let’s step back and define what health equity is. And the way we define health equity is a fair and just opportunity for everyone to fulfill their human potential in all aspects of health and wellbeing. What that means is that health and wellbeing extend beyond clinical care and even beyond health care. Our mental model for health and wellbeing includes aspects of physical, mental, emotional, social, financial, and spiritual wellbeing. That means we think that health is a human right, and not health care necessarily, but health care included, that health itself is a human right and health equity is a moral imperative that requires a business solution. We believe health equity is a priority and should be a priority for all business leaders. If you look at the cost of health care disparities in the US, it’s $93 billion in excess medical costs annually, $42 billion in lost productivity per year. In fact, there are estimates that say our economic output would increase by $2.7 trillion annually if rate-based disparities were addressed.

So what that means as we work with life sciences, plans, and health care delivery systems is that we really take a very holistic view on what it means to address health equity. We use the term drivers of health instead of saying social determinants of health. We try to challenge the factor that all the social, economic, and environmental factors are not always deterministic, but as Dr. Golden articulated, are actually a result of processes, institutions, structures that have disadvantaged disproportionately the Black and brown communities. We believe that all these health drivers can be influenced and that we, both as life science and health care leaders and, quite frankly, all of us as business leaders, need to work together to reduce disparities and make health and wellbeing accessible to all.

Heidi: Courtney, what are the challenges faced and lessons that we’re still learning?

Courtney: I think for us as an industry and certainly as we have really thought about how we could have real action and add our resources to the work around health equity, the overwhelming challenge and the lesson I think that is a continuous one to learn is around the issue of trust and authenticity. Both doctors alluded to it, historical mistrust, all the reasons why communities of color, underserved populations might have mistrust of certain parts of it and more broadly as a whole=,right? Dr. Golden alluded to implicit bias in the health care system that color how people think about our industry, but about the health care sector more broadly.

There was recent research among a nationally represented cohort of Americans finding that 32% of Black Americans, about 20% of Latino Americans, and 23% of Native Americans stated that they had been discriminated against while seeking health care because of their race or ethnicity. In our equity initiative that we set up last year where we were thinking as an industry how we could be better partners in communities of color, we set up this initiative that really focused around three key pillar areas: enhancing clinical trial diversity so that they’re a more representative population—diverse population within those clinical trials around improving health equity through the policy priorities that I stated earlier, and it’s also around creating a more diverse talent pipeline throughout our industry. But interwoven in all of that, when we started that process of what should this initiative look like, we undertook a series of focus group with folks across different parts of communities of color and different groups and the thread that ran through all of it was trust. How can I trust you? How do I know that this is a real business imperative for you? And if you do something, how do we know that you’re not just going to parachute in at the moment and parachute out later? And so I think that’s something that we have taken into account and have threaded it through our strategies on equity, across our pillars of the equity initiative, but also each of our member companies are rising to the occasion and thinking about that as well in their own operation.

Heidi: Dr. Golden, how do we look at that? How do we build trust in communities?

Dr. Golden: I think we have to take some of the lessons that we’ve learned around the importance of community engagement to deliver equitable health care. From COVID, for example, how we went and delivered COVID-19 testing, COVID-19 vaccines directly in collaboration with our community-based organizations at their sites, which were trusted locations in the community, in our senior housing, in our churches, we have to keep that same infrastructure in place to then be able to deliver other kinds of care.

Some of our diabetes self-management and care and our diabetes prevention program interventions and cancer screening, just really becoming very innovative now in delivering some of that care directly in the community. Because then again, you’re removing barriers to access that might include troubles with transportation, getting time off from work—many jobs there’s not paid sick leave. So by delivering care in the community and maybe not doing it in all of a nine-to-five time slot, right there you’re increasing access. So we’ve done a lot of things like that in the era of COVID. We need to continue that. I also think that in terms of educating the community about health care and giving them the tools and education they need to advocate for themselves that we’ve got to, again, in terms of thinking about trusted messengers, what are the media platforms that we use to get health information to the community? Again, during COVID we partnered with radio stations that the Black and Latinx community saw as trusted messengers. So we did our COVID-19 vaccine education programming in collaboration with those media outlets, as well as the partners that they work with, and we were able to reach like thousands of individuals, like in the tens of thousands.

So we need to do that. If we need to recruit to ensure that there’s equity in clinical trials and there’s diversity, we need to use those same kinds of mechanisms. So I think that that’s particularly important. I also think that it’s important for health equity initiatives within health care systems in particular to be very strongly partnered with the clinical operation arm of an organization, strongly partnered into population health.

Because again, that’s ensuring that the health equity of the communities is a key component of the strategy and really being strategic in ensuring that those community partnerships are meeting the goals—the service areas that a hospital’s responsible for, but at the same time, it’s also prioritizing those health care needs that the community has identified as primary concerns for them. I think that’s a way in which that trust is maintained. So that means that we have to have different business strategies helping to put in place, investing in a community-based organization to put the resources in place that there can actually be some clinical operations occurring at a community-based site.

So again, being creative about having health equity initiatives aligned with and supported by the clinical operations in our health system to provide those resources to accomplish that.

Heidi: Thank you for really identifying community partnership with the clinical side of things. In terms of meeting the goals, what does success look like, and how do we know when we’ve achieved that level of partnership?

Dr. Golden: From our business strategy standpoint thinking about the health system, what are our key performance indicators? What are the strategic priorities across the institution? That’s one set. What are our pay for performance measures? And is there an overlap in those things, for example, so that we can make sure that as we’re building a health equity dashboard and we’re looking at these metrics stratified by race and ethnicity and language and other demographic features that we can then identify those areas for intervention that are aligned, not only with our organizational strategy, but also with our pay for performance measures so we can make it a win-win. I think that’s important in keeping organizations focused. Because often a really great idea, if not aligned with your strategic plan, it could actually divert resources from what’s really critical.

And I will often joke around my organization that activity does not necessarily translate to progress. In order for us to make progress, we have to be really laser-focused on the metrics that we identify as a part of our strategic plan.

Heidi: Dr. Gebreyes, how are health care leaders making progress that impacts drivers of health, and what are the challenges?

Dr. Gebreyes: What are the top challenges that we as an industry face in addressing health equity? I put them in two buckets. First is what we’ve talked about a little, which is the mental model of how we think about what health equity is and what the root causes of health care disparities are.

And so when you look at the data, you often hear the data correlating worse outcomes with race, gender, income status, geographic location, et cetera. There’s a flip in the mind that sometimes happens that says that data correlation is the root cause. And so I always try to remind people that Black and brown communities have worse outcomes but the color of their skin, their race or ethnicity is not the root cause. Racism and bias, barriers to social, environmental, and economic ways of achieving health and wellbeing actually create these disparities. We as leaders and we as individuals need to very strongly keep in mind that race is a social construct and that we have to separate correlation from causation.

In July of 2021, we surveyed 300 leaders at leading health systems and health plans to understand if they think drivers of health are important in improving health outcomes and reducing health care disparities and what they’re doing about it.

And what we learned is that the majority of these leaders do believe that it’s critical to address drivers of health. In fact, what we found is that 80% of health care organizations say they’re screening their patients to determine whether they might need active food banks, vouchers, transportation, but only 35% have actually established new partnerships to address the identified needs within their screening.

The other thing that was highlighted is that value-based care, which is a way of paying for outcomes and rewarding for helping achieve health instead of providing health care services, in 2017 the same survey said that 20% of health system leaders were embedding drivers of health within their value-based models.

And now in 2021, it’s 68% of health system leaders have said that they really believe that addressing drivers of health will help them achieve improved outcomes, but there’s still a gap in what they’re actually doing about it. And then finally, and this is something that I think I would ask every life science and health care organization and even other business leaders to pay attention to is that our data and our survey showed that the challenges that employees of health plans, life science companies, and health care delivery systems faced as related to drivers of health received the least attention from those who responded to our survey. Fewer than half of the health care organizations were screening or providing programs to their own employees. And so this notion that disparities, bias, barriers to social, economic, environmental access is something that happens outside of your organization and not within your own organization, but it’s out there in society is a myth we think it’s really important to debunk and we would encourage all business leaders to start within their organizations first.

Heidi: Out of this survey, the organizations as you’ve described are screening but the imbalance, as it implies, is that the act of connecting to the services of what you do next is still a good place for a lot of investigation.

Dr. Gebreyes: And not only should there be more action in terms of addressing those gaps that are identified, but we also need better tools to measure the impact on investment. We’ve done a lot of work with a number of our clients to say for every dollar that you spend in a housing program versus a smoking cessation program versus transportation, how much of an improvement do you see in the outcomes that you’re trying to impact? So it’s important to do something and it’s important to have the right tools and mechanisms and process to measure whether that intervention or that investment that you’re making is actually leading toward better outcomes and reducing health care disparities.

Dr. Golden: I think that linkage is so important between if you’re going to screen, then you definitely want to set up the referral process and then measure the outcomes, as was just mentioned. And I know that for many of our health care providers, if they identify a need but don’t have the guidance on how to address it, that can be a source of moral distress for them. We’re thinking about developing our social determinants of health screening strategy at Johns Hopkins Medicine. We have been partnering with our Office of Population Health and have identified some uniform screening questions to use across the system and also identified a vendor that will be our collaborator for a community resource referral because that linkage is so critical because you’re not going to be able to measure the outcomes or improve them if you don’t make those linkages.

Dr. Gebreyes: Dr. Goldman, I love that you said that, because I think that there are organizations that are really leaders and shaping and modeling the right actions in this area.

Heidi: So as we close the show, we’ve discussed a lot of strategies and potential solutions. Courtney, what’s one thing you would want listeners to take away from our conversation today?

Courtney: As I’ve been listening to our conversation, I’ve been reminded of a quote from one of my mentors, Dr. Frita Louis Hall, she said to me all the time, “Health is a crown worn by the healthy, but only seen by the infirm.” And in order to move the needle on any of this, you have to push. I think going forward from this conversation, we really have to dig into the data, especially what we’ve seen during COVID and whatever happens in the new normal, as I call it, what worked, what didn’t with those metrics that Dr. Gebreyes talked about. How do we scale up what worked and how do we say these other things that we tried weren’t especially helpful? How do we incentivize the health care system more broadly to address health equity as a business and moral imperative? How do we make use of this data that we collect and how do we do a better job of collecting even more robust data so that we can help policymakers, both state and federal, prioritize solutions on these drivers of health so that people can reach their own level of optimal health and wear their own crown of health?

Heidi: Well said Courtney. Dr. Golden, let’s hear from you.

Dr. Golden: And I think what I would add is if I think about the work that we’re all doing in this space, I just want to leave with our listeners that diversity and inclusion in health care is a matter of life and death, because if we don’t address our biases, they can adversely impact a patient to have an adverse outcome. And having equitable practice dismantling structural racism in health care is just as critical to equitable patient outcomes and patient safety as washing our hands is to preventing central line infections. And so I feel like we’re at a place as we think about moving health equity forward in this space about where we were with patient safety and quality about 15 years ago. And as Courtney said, keep pushing this field forward. And we also need to integrate equity into everything we do, everything we think about across health care. Think about who’s being left out as you’re developing any new processes. We’ve learned a lot from COVID, things that we thought would take 10 years to do happened in 10 days when they had to. And so what I think we’ve learned from that, and this is my favorite pandemic quote, I don’t know who said it originally, but I received it a few weeks into the pandemic and it said, “Nothing should go back to normal. Normal wasn’t working. If we go back to the way things were, we will have lost the lesson. May we rise up and do better.”

Heidi: Last words, Dr. Gebreyes. I know this is a tough order, but what would you like to impart on our listeners?

Dr. Gebreyes: I would wrap my thoughts around as we think about health equity and what all listeners should keep in mind is that if you’re in business, any sector, if you employ people, if you’re a taxpayer, if you’re a clinician, or just an individual taking care of a loved one and taking care of yourself, health equity is important to you, and it’s important to everybody who is in your world.
And so I think I would truly say that we are all in the business of health and wellbeing, and it’s important for us to remember that we have to really be bold and challenge traditional orthodoxies around what does it mean to make sure that health and wellbeing is accessible to all. I think I would ask all listeners to redefine the expectations that you have of yourself and the leaders that you work with.

And maybe the third thing is to really call on your own organizations, your peers, and the greater community into action, because while health equity is important to us all, no single person can single-handedly change or have the impact that we need to have. It’s going to take every single one of us. And so we really must link in a common purpose and vision to create a world in which health equity and health and wellbeing are accessible to all.

Heidi: I couldn’t agree with you more. To dismantle dysfunctional and broken systems, health equity should be an organization’s North Star. By aligning strategies, policies, and investments, we can help break down silos and advance equitable health outcomes at scale so that every individual has the fair and just opportunity to achieve their full potential in all aspects of health and wellbeing.
I want to thank my guests, Dr. Kulleni Gebreyes, Courtney Christian, and Dr. Sharita Hill Golden for joining me on Tales of Transformation. Thank you.

Dr. Gebreyes: Thank you so much.

Dr. Kulleni: Thank you.

Dr. Golden: Thanks for having me and for having this conversation.