Editor’s note: Joseph Betancourt is one of the theme advisors for the June 2017 Health Affairs equity theme issue.
The passage of health care reform and current efforts in payment reform have fueled a significant transformation of the US health care system. An entire new set of structures is being developed to facilitate increased access to care that is cost-effective and high quality. High-value health care is the ultimate goal. Guided by the 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, the nation has charted a path to deliver care that is safe, efficient, effective, timely, patient-centered, and equitable. There is no doubt that significant gains have been made in this effort, particularly in the area of patient safety. However, one key pillar of quality—achieving equitable care—has garnered significantly less attention than the others. Equity is the principle that quality of care should not vary based on patient characteristics such as race and ethnicity, gender, geographic location, or socioeconomic status.
The inclusion of equity among the pillars of quality emerges from longstanding research that has identified disparities in health and health care based on all of these patient characteristics. For example, minorities are significantly more likely to be diagnosed with and die from diabetes compared to whites. There is little doubt that negative social determinants—such as lower levels of education, lower socioeconomic status, unsafe neighborhoods, and “food deserts”—disproportionately impact minority populations, and thus contribute to their poorer health outcomes. Minorities are also more likely to be uninsured, and thus less likely to have a regular source of care, more likely to report delaying seeking care, and more likely to report that they have not received needed care — resulting in avoidable hospitalizations, emergency hospital care, and adverse health outcomes.
To further complicate matters, the 2002 IOM report Unequal Treatment found that even when minorities and whites had the same insurance and socioeconomic status, and when comorbidities, stage of presentation, and other confounders were controlled for, they still often received a lower quality of health care than whites. While these examples focus on disparities related to race and ethnicity, more recently disability and sexual orientation have been included as key components of equity, as well.
Earlier this year, Don Berwick laid out his vision of what will be “era three” of medicine and health care, sharing his perspectives about where health care has been, and where it’s headed in this country. As someone who has focused on health equity for close to 20 years—with a particular focus on racial and ethnic disparities in health care—I thought this was an interesting lens to view equity through, examining where this field has been, and where it is headed.
The First Era of Health Equity
With the release of Crossing the Quality Chasm, followed shortly after by Unequal Treatment, the first modern era of equity was underway. I say “modern” because the issue of disparities and equity was an issue well before the early 2000s, and to dismiss this reality would do a disservice to the many leaders and incredible work that occurred in decades past. Nevertheless, given the imprimatur of the IOM, these reports made disparities real and the need for equity legitimate, and caused health care leaders to take notice in ways they hadn’t before.
Equity was no longer part of an activist agenda, but instead an issue that required mainstream focus and attention. That’s not to say that leaders jumped into action. In fact, the predominant sense across the nation within health and health care was one of “not here, not me.” Aside from progressive leaders and early adopters who began to place equity on the same footing as the other pillars of quality, the overwhelming majority either remained reluctant to admit that disparities existed in the health care settings they oversaw, or went on the slow burn, multiyear path of “studying the issue and what could be done.”
Nevertheless, leaders were slowly socialized with facts in this period, and the mantra of “no one suspect, no one solution” allowed them to better understand the multifactorial nature of the problem, and the complexity of solutions needed to address them. Organizations such as the Joint Commission, the National Committee for Quality Assurance, and the National Quality Forum—often supported by foundations such as The Commonwealth Fund, The California Endowment, and Robert Wood Johnson—began to explore how they could exert their influence to drive change in this area. Whether through accreditation standards, incentives and awards, or new measures, these organizations set the table for significant progress in legitimizing equity and the need to address disparities. During this time there was little discussion about other areas of disparities beyond racial and ethnic disparities. Disparities that impacted individuals by disability status or sexual orientation, and the impact of social determinants on health, health care, and health disparities received limited attention. Most importantly, there wasn’t much work on solutions to speak of. All of this notwithstanding, the first era was one of energy, optimism, and the building of some key foundational elements of the field.
The Second Era of Health Equity
The passage of the health care reform in 2010 and the push to increase value in health care, including achieving the triple aim of better care, better health, and lower costs, heralded the beginning of the second era of equity. A lot of energy was devoted to health insurance enrollment, and a litany of new structures (and acronyms) evolved to improve care delivery and to deliver on value, including ACOs (Accountable Care Organizations) and PCMHs (patient-centered medical homes), among others.
New cost “pressure points” such as readmission penalties and financial skin-in-the-game for population health, patient safety, and patient experience also took root. The emergence of electronic health records and meaningful use requirements became all consuming. “Hot spotters,” “super-utilizers,” and the “duals” (individuals covered by Medicare and Medicaid) became targets for new efforts to improve community health and control cost. The net-net here was that much of the oxygen was sucked out of the health care room and fledgling activities focusing on equity and disparities were receiving little attention. Foundations and other organizations that had been essential in the first modern era of equity now moved away from equity- or disparities-specific funding or activities in favor of “mainstreaming” this work (folding disparities into quality work, or as part of healthy communities’ agendas, for instance) or focusing on other more pressing areas.
Despite this, advocates for improving quality, addressing disparities, and achieving health equity began to connect the dots for health care leaders, highlighting that if they really cared about quality and controlling costs, they needed to care about equity. Research had demonstrated that minorities, when compared to whites, tended to suffer more medical errors with greater clinical consequences; have longer length of hospital stays for the same clinical condition; experience higher rates of avoidable hospitalizations and 30-day readmission rates for congestive heart failure; experience more test ordering for similar conditions (particularly when there was a language barrier); and were under-used clinically beneficial, evidence-based care. Improving quality, addressing disparities, and achieving equity was not just the right thing to do, but also the smart thing to do, given the new financial structures developed to drive quality and value.
During this time, increasing attention was paid to the social determinants of health, and new efforts were launched to collect patient data related to disability and sexual orientation. We also began to see the first unintended consequences of health care transformation: for instance, hospitals that historically served poor, underserved, vulnerable, and minority communities were subject to significant readmissions penalties. A fierce debate began about whether organizations that serve larger vulnerable populations should be able to risk-adjust for patient socioeconomic status, thus allowing them a better chance at success. Proponents feel this is appropriate and reflects reality; opponents suggest that risk adjustment creates two standards of care, one for hospitals who care for vulnerable populations, and another for those who don’t — in other words, it lets the former off the hook for delivering high-value, efficient, and effective care.
In sum, the second era of equity is one of rapid flux and a turning away from disparities and equity explicitly, while at the same time a period where a strong business case for addressing disparities and achieving equity has been made. The equity umbrella also began to expand to other groups and issues—such as individuals with disabilities and those from the Lesbian, Gay, Bisexual, and Transgender community—and incorporate the importance of the social determinants of health. Solutions still are few and far-between, hard to come by, and difficult to sustain — yet the hope remains that the movement to high-value care will finally make achieving equity a smart business decision.
The New Era of Health Equity
The new era of health equity is upon us. Health care reform marches forward, albeit with some real challenges ahead: care is costlier than anticipated under Obamacare, commercial insurers are pulling out of exchanges, and fickle political winds remain a constant threat. The real push towards value begins with the best ABC of health care yet—an acronym within an acronym—MACRA. The Medicare Access and CHIP Reauthorization Act is the Centers for Medicare and Medicaid Services’ (CMS) effort to shift how providers are paid, from quantity of care to quality of care. Already we see the unintended consequences brewing, as ACOs are the better rewarded option in MACRA compared to the Merit-Based Incentive Program (MIPS), yet are less likely to exist in minority communities. ACOs are also less likely to recruit providers who take care of large minority populations.
That being said, several promising opportunities are on the horizon. First is the much greater focus on the social determinants of health. Serious efforts, especially as part of population health, are underway to meet the broader social needs of patients. This will, if constructed with attention to the needs of diverse populations, undoubtedly go a long way to address disparities and foster equity. Second, much more attention is being paid to all aspects of equity, and not just racial and ethnic disparities. Third, activities focused on diversity and inclusion, and especially new conversations about racism, implicit bias, and stereotyping as root causes for disparities, are bubbling up now more than ever before. This is likely a direct consequence of the coverage of police violence against Black citizens, the Black Lives Matter movement, and the current and toxic political climate around race relations. Although difficult and painful, it is fair to believe that these difficult conversations can take us to a better place on issues of disparities and equity, especially in health care. Fourth, we are seeing major campaigns encouraging hospitals to place a premium on equity, most prominent among them being the American Hospital Association’s annual Equity of Care Award, and its #123forEquity pledge campaign, which over 1,300 hospitals nationwide have signed on to. Fifth, CMS has developed a major Equity Plan for Medicare that looks to drive the health care system toward a robust set of activities focused on addressing disparities and achieving equity, using CMS’ influence as the nation’s largest payer.
These are just some of the major trends and activities that will define the new era of health equity. It is important, however, to continue to highlight the importance of having multiple stakeholders at the table. Currently, health plans have been minimally engaged in this work, and the National Health Plan Collaborative, the nation’s first and only effort to bring large health plans together to partner around addressing disparities and achieving equity, has long since faded into the sunset. What is needed now are concrete strategies, solutions and interventions to address disparities and achieve equity in all its facets. More research documenting problems is nice but unnecessary. We need to move beyond diagnosing the problem to addressing it. If we are in fact going to emerge from this next era of health equity successfully, the summary we’ll write in 10 years should highlight all the new, sustainable, and financially viable interventions that finally allowed us to thread the needle and sew together cost, quality, safety, equity, and value for the purpose of eliminating disparities once and for all.