By Evan Osborne, MPH, RT(T)
Communities are facing a crisis in healthcare. Patients are choosing to feed their families over purchasing essential prescriptions for chronic diseases. Due to a lack of transportation, vulnerable and underprivileged demographics are purchasing cheap, unhealthy non-perishables at convenience stores rather than health-conscious options at grocers just a few miles away. Non-English-speaking patients are being discharged from hospitals only to return because they did not understand the post-discharge instructions. These are just a few challenges faced daily in communities suffering from low health equity.
In 2014, evidence-based research ranked the U.S. as last overall in comparison to 11 industrialized nations measured in quality, efficiency, access to care, equity and healthy living (Mahon, 2014). In September 2015, the Centers for Medicare and Medicaid (CMS) Office of Minority Health released their equity plan for improving quality in Medicare. The mission of this plan strategized the benefits of advancing health equity by improving quality of care within minority and other underserved Medicare beneficiaries (CMS.gov, 2015). This proposal was catalyzed by the Affordable Care Act, Healthy People 2020 and other leading federal agencies driving nationwide health initiatives. Furthermore, Medicare spending grew 4.2% to $705.9 billion in 2018 (CMS.gov, 2019). This historical data coincides with other trends highlighting the use of excess funds and care being directed towards disparities within specific populations and demographics. Influenced by modern healthcare’s transition from fee-for-service to value-based purchasing reimbursement models, the risk in caring for populations suffering from health disparities has grown exponentially.
What is Health Equity & Why Should It Be Addressed?
Health equity pertains to the absence of avoidable, unjust, remedial disparities typically observed in minority and disadvantaged populations. Low-income, limited education and employment status are characteristics that can jeopardize the health of specific demographics. The cost of healthcare within a household can quickly become a burden and drive families into poverty when there is a need to treat chronic diseases. Preventative care and healthy lifestyle coaching are absent in poverty-stricken communities as they are, in most cases, unavailable in geographic areas with high populations of underserved Medicare beneficiaries. Without this education and access to an environment promoting awareness and encouraging evidence-based health practices, health complications are compounded, reducing the probability of positive outcomes. In addition, chronic conditions lead to a domino effect of care management challenges that require complex teams of medical specialists to be in position to address severe levels of illnesses. These are daily challenges faced by licensed medical professionals seeking to heal the fragile patients assigned to their care.
How Does Health Equity Impact Providers & Payors?
Patients seeking medical help with multiple, uncontrolled comorbidities bring extra risk to health facilities. Juggling chronic issues that have not been addressed become a care-management challenge and nightmare. Gaps in care, sometimes due to a language barrier and education level, develop and lead to further complications. A cycle commences as vulnerable demographics suffering from chronic disparities return, seeking medical attention for uncontrolled, high-risk morbidities, which can ultimately lead to death within a hospital. These cycles ding hospitals with readmission penalties, negatively affect mortality rates and decrease national rankings of both providers and payors involved.
Research shows populations facing health equity challenges suffer reduced lifespans. This lower life expectancy raises the mortality risk of these patients seeking specialized and acute care over and over again. High acuity demographics, such as homeless populations admitted into hospitals, also pose a risk to surrounding inpatients seeking care. Healthy hygiene practices are either not followed or proper facilities are unavailable to address cleanliness. In addition, vaccinations, or the lack thereof, can lead to asymptomatic carriers entering health facilities seeking a clean, aseptic space.
In 2018, United Health (UH) began paying for their members’ housing (Japsen, 2018). This was catalyzed by a case where one of their homeless members checked into an emergency department over 250 times and was readmitted on 32 separate occasions in less than three years. UH was able to determine that the cost of rent was less than the alternative, inpatient billing charges. In 2009, the Urban Institute in Washington, D.C. predicted that disparities alone were going to cost health insurers $337 billion between 2009 and 2018, including $220 billion for Medicare (Waidmann, 2017). Focusing efforts on addressing health disparities, and the challenges these patients face, will significantly reduce the risk of return visits and readmissions, ultimately improving healthcare quality outcomes.
How Can Providers & Payors Be Rewarded for Addressing Health Equity?
Steps can and are being made to reward payors for addressing health disparities through statewide health exchanges, such as Covered California. Covered California incentivizes payors tending to health inequity challenges within the member populations. Millions of dollars have been put on the table as bonuses paid out to health insurance companies successfully aligning with mandated initiatives. In 2018, Blue Shield of California (BSC) responded by hiring staff specifically to build and manage a program focused on health equity. The initial challenges this program faced was acquiring data along with needed documentation to establish a baseline assessment on health equity within health facilities serving BSC members. These growing pains are catalyzing the movement to capture data providing actionable insight for decision-makers within the healthcare industry.
Through joint efforts between payors and providers, health equity can be addressed by way of quality collaboratives. Quality collaboratives provide infrastructure for incentivized reporting, as well as leverage in-hospital contract negotiations and health exchange incentivization programs. Putting dollars at-risk around measures specifically associated with addressing health equity is powerful. Incentivizing providers to report ethnic, race, sexual orientation and socioeconomic metrics will lead to tangible solutions payors can use within their health equity programs.
The foremost step for health organizations to be rewarded in tackling challenges and risks associated with low health equity is through documentation and risk-adjusting analysis. In 2016, the development of official coding guidelines and the incorporation of the ICD-10-CM Z codes by CMS and Center for Disease Control’s (CDC) National Healthcare Safety Network (NHSN), were steps in the right direction. Capturing key contributing factors, such as poverty, race, geographic location and language are all attributes needed to understand patient populations. These analytical opportunities help paint a transparent picture of performance rates within healthcare facilities, addressing the challenges low health equity can bring.
How Can Health Equity Be Addressed Through Technology?
According to Paula Dressel from the Race Matters Institute, “The route to achieving equity will not be accomplished through treating everyone equally. It will be achieved by treating everyone justly according to their circumstances.”
In this new age of tech-driven healthcare practices, we have tools available that can level the playing field for providers and payors addressing the needs of those facing health disparities. A way technology is having a big impact is through modified enhanced electronic health record (EHR) systems. Incorporating population health modules and risk-adjusting, documentation improvement solutions will enhance provider practices to capture evidence of health disparities leading to actionable insight. Furthermore, bridging the gap in quality reporting between health facilities, payors and healthcare-regulating government agencies can be done by standardizing payor-provider data portals and improving collaborative efforts with Health Information Exchanges (HIE). These joint endeavors will lead to appropriate distributions of value-based revenue supported by increased case mix indices, improved mortality and severity of illness reporting; all byproducts of clinical documentation improvement and meaningful use of data standards.
Giving credit where credit is due by accurately risk-adjusting socioeconomic disparities and vulnerable demographics will pave the way in rewarding health organizations for their efforts in assisting communities to overcome challenges associated with low health equity.
About the Author:
Evan Osborne is a Manager with Dacarba LLC, a subsidiary of Opportune LLP, specializing in the field of healthcare quality. Evan has over 10 years of professional experience in direct patient care and hospital systems with a deep background in quality improvement, oncology, project management and program development. Evan earned Bachelor degrees in Biology at Western Oregon University and in Radiation Therapy at Oregon Health & Science University. He later earned a Master’s degree in Public Health at the University of Massachusetts, Amherst, and is currently completing a Doctor of Business Administration at California Southern University.