5 Steps for Addressing Racial Disparities in Health
Effective action requires discomfort. Goodwill is a sound motivator, but without willingness to assume responsibility, efforts to change racial inequities black and brown individuals face will be fruitless.
In the “The Road to Equity: Examining Structural Racism Virtual Forum,” hosted by the Center for Medicare and Medicaid Services and Office of Minority Health,, speaker Karthik Shivashanker brought to light how health institutions hold the power to change health outcomes for their patients.
See more of what the webinar covered here.
The work that needs to be done goes beyond what the standard is offering. His home institution, Brigham and Women’s Health, implemented a five-driver framework to achieve patient equity that takes on an inherent high-liability approach. He hopes other health organizations can adopt a similar approach.
The framework is as follows:
1) Integrate equity into quality and safety risk analyses
2) Use quality and safety education to anchor that work
3) Use data to support equity improvement
4) Leadership awareness and engagement
5) Organizational accountability
The first step to launching this framework is to ask the question, “Are there inequities contributing to this risk? And if so at what level?: Implicit, interpersonal, institutional or structural?”
Oftentimes, as Shivashanker highlighted, the health system takes an identity-blind approach to care. This foundational approach will offset any equity efforts, because without knowing the root causes of disparities, the wrong solutions will never become the right ones.
Shivashanker gave the example of a health organization which may see a 60-year-old patient who has trouble getting her medication at the pharmacy. When considering a care plan for her, the hospital may eliminate all other identity factors, because they see it as being less biased. However, in doing so, they’re failing to see that she is a non-english speaking woman from the Dominican Republic, with low vision who has trouble getting her medication at the pharmacy. The second situation now gives context and allows clinicians to pinpoint the causes of her disparities so they can begin to address them.
After the first year of introducing this approach, Brigham went from identifying zero inequities in their safety risk analyses and quality structures, to identifying hundreds in the year after. They could then begin to implement system level improvements and policy changes. To affect change, health systems have to hold themselves accountable to higher levels and recognize power is in their hands.
In fact, Brigham has introduced a proactive “antiracist agenda” for medicine, in conjunction with their five-driver framework. In a Boston Review article, written by Brigham staff, the authors argue that standard options for addressing racial inequality, such as implicit bias training and objectivity checklists for decision making are not sufficient.
“Implicit bias training and checklists offer indirect solutions where more direct forms of race-explicit action are available; the objectivity aspired to in clinical criteria is also inevitably tainted by the pervasiveness of structural racism,” the authors of the article say.
After studying 10 years worth of patient data, researchers at Brigham found that black, hispanic and latinx patients were more likely to be worse off in their cardiac treatment plan than white patients. This disparity wasn’t fully accounted for by insurance status, established links to care, other medical conditions nor the socioeconomic status of a patient’s neighborhood. This meant that something internal was happening as well. What they found was that their white patients were more likely to be admitted to their specialty cardiology department, whereas these patients of color were more likely to be referred to general medicine. This was a problem because those admitted to cardiology saw improved outcomes and had an overall more comfortable experience. A statistic that surely widened health disparities.
To remedy this, Brigham started testing a system that flags a patient of color’s EMR and suggests the provider admit them to the cardiology department, rather than just relying on provider recommendation or patient self-advocacy. This does not mean that white patients then receive lower-quality treatment, just that there are proactive steps being taken to ensure patients of color are getting the same high quality treatment. Equality is giving everyone the same resources; equity is giving those who need extra resources to achieve the same outcomes the ability to do so.
While colorblind approaches to care attempt to harmlessly promote equality, their unintended consequences have power, Shivashanker highlighted. He said there’s a tendency for health systems to focus on downstream clinical measures, like hemoglobin A1c or hypertension. What might happen is that a health system could throw a lot of resources at a relatively small group of privileged patients. The health system inherently favors these patients because of insurance status, for example. The health system will see metrics improve for this small group. They will think they’ve done well. An affluent academic medical center like Brigham is able to supply this funding, but a safety net hospital might not be able to do the same. Purely looking at data, it would seem as if the safety net hospital is doing worse, even though they are treating a greater share of patients who have been and continue to be disadvantaged. Historical traumas and disparities cannot go unaccounted for when implementing and rating new health initiatives.
“When you roll out an intervention based on hemoglobin A1c, what inevitably happens is that patients with privilege and resources are more likely to seek advantage because they have the ability,” Shivashanker said. “And the folks who are struggling don’t. And so even then you see this natural separation between the have and the have nots. So once again, without the right balancing metrics, a well-intentioned equity effort or set of metrics can actually exacerbate things.”
Shivashanker encouraged the audience to think about how the industry can incentivize health systems to compete for patients that have been historically marginalized, rather than for those with resources.
How Telehealth Can Bridge Race-Driven Care Gaps
Telehealth is a powerful tool that has the potential to create, exacerbate or remedy disparities. We’re advocating for telehealth use in conjunction with equitable principles, such as those Shivashanker mentioned. Shivashanker said the equity framework starts off simple: increase access and improve transitions in care.
Access solicits questions such as “Are you taking care of a fair share of your black, brown and Medicaid patients?” Telehealth portals integrated with patient data can be a great source to begin to explore possible population imbalances that exist.
Transitions, Shivashanker said, prompt thoughts such as “Are you equitably offering them services once they’re in your care?” Proactive systems, such as the one at Brigham, can use virtual care to flag underserved patients and ensure they get a little extra help than they would normally.
Telehealth can also help providers gain insights into a patient’s home. The materials an individual uses for the visit and their surroundings may not always be definitive indicators of social determinants of health, but they can be hints. These hints are sometimes crucial to catch when patients are not always able or willing to fully express their current lived experiences.
Thinking of virtual care initiatives like these go beyond implementing basic video visits. Remote Patient Monitoring (RPM) can help hypertension patients stay informed and connected to their providers. Virtual health coaches help these patients make lifestyle changes, while being culturally inclusive, so they can develop care routines that fit in seamlessly with their lives. E-visits ensure patients can get their questions answered when they only have a few minutes in their day, whether it be because of work or other responsibilities. The affordability and continuity of telehealth makes care an everyday conversation for underserved patients. With telehealth, patients get a voice and the opportunity to be an active participant in their own health.
Value-based care environments will undoubtedly drive telehealth usage and incentivize providers to increase quality for these disadvantaged patients. Putting telehealth first means putting patients first. So, let’s start being proactive.
