4 Key Focus Areas for Payer, Provider Health Equity Work

The newly minted Deloitte Health Equity Institute’s leader, Kulleni Gebreyes, MD, outlined four key areas for supporting health equity work.

It’s easy for health equity work to devolve into a bit of analysis paralysis, leaving even the best-intentioned people stuck questioning how to progress forward, according to Kulleni Gebreyes, MD, a former ED doc turned Deloitte consultant.

After all, health equity is an enormous problem, driven in large part by the nation’s racist past and the way that has shaped institutions—all institutions—today.

But according to Gebreyes, who is Deloitte's US consulting healthcare sector leader and recently appointed leader of the Deloitte Health Equity Institute, the industry can make the health equity challenge smaller if everyone can mobilize.

“As an individual, as a professional, as a leader, as an organization, each one of us can contribute to advancing health equity in some way, form, or fashion,” Gebreyes told PatientEngagementHIT in an interview.

“People should not be paralyzed by the complexity or the magnitude of the problem, but just find what they can do within their lane in order to help us all have a better society. It's going to take all of us. But if we each focus on the individual or organizational impact that we can have, our success is guaranteed.”

That’s why Deloitte set up the Health Equity Institute, Gebreyes continued. On top of the company’s goals to aggregate health disparities data and partner with business leaders, Deloitte is laser-focused on the how-to. Healthcare needs to move away from “admiring the problem,” Gebreyes said, and zero in on actionable information that can move the needle on health equity.

According to Gebreyes, healthcare organizations can divide their health equity work into four domains: the organization, offerings, community, and ecosystem.

Each of these domains ensures healthcare organizations do not allow their health equity work to fall through the cracks in any way. That’s admittedly an easy thing to have happen; a healthcare organization might invest millions of dollars into addressing food deserts in its community—a noble pursuit—but also tie up millions of dollars in contracts with vendors that espouse values that do not align with equity.

This four-pronged approach to health equity is a digestible path to ensuring organizational culture emphasizes equity at all junctures.

Organization

In terms of organization, Gebreyes said payer and provider leadership need to assess how they themselves are pushing for equity themselves and within their own workforce.

“It's looking at collecting data and doing data insights to understand more about your workforce. Are you advancing health equity in who you hire, who you recruit, who you retain?” Gebreyes offered as examples.

That has a serious impact on health equity for patients, most experts agree. Previous data has shown when patients can visit a provider who looks like them—whether there is racial, gender, or sexual identity concordance—they report a better healthcare experience.

It’s evident in outcomes, too.

“When you look at the data and you look at infant mortality, what the data shows very clearly is that even after equalizing for income, education status, all the true risks, that the Black infants who received their care from White physicians are more likely to die than Black infants who received their care from African American physicians,” Gebreyes said.

And given the stark infant and maternal mortality health disparities observed in the US, that’s a staggering problem.

Addressing that issue will require hiring out a diverse workforce, which Gebreyes acknowledged will be a long-term effort.

“As you're thinking about long-term, and we're seeing organizations also focused on this, spend time and money training a workforce that is more diverse,” Gebreyes urged. “That starts in high school and college and medical school, that really, you double down on investing in a workforce that is more diverse than the one that exists today.”

But in the near term, diversifying the workforce also means arming the existing practice staff with the tools to be culturally responsive.

“One of the things that we can do is really train the workforce that you already have on unconscious bias and implicit bias because I think that most people, at least this is my philosophy, have best intentions in mind,” Gebreyes said. “Sometimes they don't even understand the bias that they're bringing in when they're making medical decisions.”

“Are you mandating cultural competency and understanding of implicit bias for those within your own organization?” she continued. “That spans in HR department and also across all functions and business units.”

Offerings

When examining organizational offerings, Gebreyes urged hospitals and clinics to consider where they set their baseline. In other words, for whom is the organization designed? This can manifest itself in patient navigation, whether the facility is amenable to public transportation and rideshare or whether it’s available to people who can’t get time off work during normal business hours.

“Where are your clinics located? What are the operating hours? Who are your clinicians? Is your plan thinking about benefits design? What is the norm? What's the default that you've designed around and what's being reimbursed versus not being reimbursed?” Gebreyes posed as considerations.

A lot of healthcare and benefits design and best practice centers the White, adult, male patient, but Gebreyes recommended organizations reassess their actual patient panel. Are there other demographics an organization should consider as the baseline? How many spokes should that organization actually develop?

But even beyond benefit or service design, Gebreyes pushed healthcare organizations and payers to look at how they determine clinical quality.

“Are you demanding better quality? And not quality just as an aggregate number, but understanding that that data needs to be broken down into race, gender, geographic differences so you can close the gap,” she noted.

This follows a key industry trend right now. In order to push forward in health equity, both payer and provider organizations need to look at clinical quality as stratified by demographic. This will reveal where the gaps are and equip organizations with the knowledge for building out better programming.

That’s not always comfortable, Gebreyes pointed out. When an organization stratifies patient safety data by race, for example, it might find that Black patients experience patient safety events more often than White patients, and that could make the organization look or feel guilty and complicit.

Gebreyes said organizations need to lean into that discomfort if they want to drive change.

“Embracing that discomfort and knowing that we are all biased in some way, shape, or form, and our systems are built on a history and generations of bias, and so we just now need to measure it, that's a level of comfort that needs to be addressed,” she stated.

Community

The community domain, as Gebreyes describes it, is what may come to mind when considering some of the first social determinants of health investments. These are the health system grants awarded to affordable housing groups or the backing hospitals give to food security programs like food pantries.

These efforts are vital, Gebreyes said, because community health partnerships can help ameliorate the downstream impacts that so often fuel health disparities.

“Are you investing in those who live around you?” Gebreyes queried.

It is important for healthcare organizations not yet investing in the community to understand how community investment impacts them as a business, she added.

“We've worked with not just healthcare organizations, but multiple industries that say, ‘Social determinants of health and racism and bias exist outside of us that doesn't impact our employees,’” Gebreyes stated. “And what we find is, at minimum 20, sometimes 50 percent, of your population as a business is actually impacted by all of food deserts, medical deserts. So how can you be a better partner in your community?”

Ecosystem

The ecosystem domain asks healthcare organizations to consider the vendors and other businesses with which it has contracts, Gebreyes said. Organizations need to assess whether they are giving their dollars to like-minded businesses, and when possible use those contracts as leverage to push forward organizational health equity values.

“For any vendors that you're paying, how do you make sure that their policies and the way they practice actually is aligned with your value system as well?” Gebreyes posited. “And so there's a way to amplify your voice, both in contracts as well as in what you put out there, so you can activate those around you.”

Building a business case for health equity

None of this is to say that health equity work is easy, Gebreyes noted. Organizations need to invest heavily to make this all happen, and as a business it is easy to be wary of the high price tag.

“But there is a business case around advancing health equity,” Gebreyes asserted. “We can't make that false choice or continue that narrative that says you have to do good, or you have to do well. There's room for both.”

Continue with the infant mortality example, something Gebreyes said is easy to galvanize around. ICU hospitalization for infants is extremely costly and more prevalent in communities of color for a myriad of reasons.

But implementing upstream interventions—access to prenatal care, access to secure housing, access to nutrient-rich food—are extremely low-cost and effective preventive measures.

Both payer and provider organizations need to do the cost analysis to understand how these benefits could in fact save their organizations money, Gebreyes noted.

“And then the human impact speaks on its own,” she concluded. “Doing the right thing results in less medical costs, less loss of productivity in the economy, and just the human impact is immeasurable.”

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