In Reforming Health Care Post-Pandemic, Racial Inequities Must Be a Target

By Theresa Hush

As the country reopens, health systems are eager to bring patients back. But we can’t go back to business as usual, even if that were possible. The current moment insists that as we open up, we also address inequity in health care and create solutions for better access and outcomes across all patients. COVID-19 affected Black and Latinx Americans far worse than whites, driven by both higher risk and poorer access to care.  It’s time to honestly assess how we can eliminate these biases to provide better health to everyone, regardless of race.

There is overwhelming data that shows that people of color, especially Black Americans, suffer the worst outcomes and higher mortality across all diagnoses. The tendency is to blame outcomes on patients. Health care is full of language that implies that Black women or Black men, depending on the medical condition, are not able to “manage” their conditions. But the truth is that we don’t always know the reasons for more serious risks, and people don’t have full control over their circumstances due to various social and economic factors.

In the near and far future, economics will require reducing costs across all patients. There will be tremendous pressure to reduce the risks that lead to higher costs.  That financial reality will become clear to providers as well as payers, employers, and consumers as health care losses mount under the pandemic. 

America’s Health Care System Is Failing Black Americans

The data on COVID-19 deaths clarifies who has fared worse in our health care system. Vulnerabilities to the virus are supported by a strong body of data about chronic health risks for people of color: higher rates of heart attacks, deaths by metastatic breast and other cancers, maternal mortality and reproductive system disease and cancers, autoimmune disease and chronic stress. Likewise, risk factors like diabetes, hypertension, and obesity are significantly higher in black communities.

But well-documented racial disparities have not yet generated an urgent commitment from providers, health plans, or government for real change. The challenge is big, but we must acknowledge and begin to address lack of access to consistent primary and specialty care, behavioral health, insurance, healthy food, housing, and employment.  The health care industry, pummeled by loss of revenues and higher costs during the pandemic, cannot build a system that can weather the economics of the next two years without addressing marginalized patient populations — because both the pandemic and the economics that will push the industry toward financial risk would be set up to fail.

The Reopening of Health Systems Could Lead to Further Inequities

As health systems balance risk of the virus and patient flow while they reopen services, they continue to look to telehealth to fill the gap in care. Many consider telehealth to be a permanent fixture in health care and want to vastly expand it.

But a telehealth expansion strategy must ensure that it can reach all patient populations. We haven’t yet calculated who has benefited from telehealth during the shutdowns, nor evaluated outcomes across race, ethnicities, and language–and the availability of high speed internet and personal computers. We need to measure these interventions to ensure that we are not reducing access and worsening health. 

Risk Stratification and Social Determinants Can Help or Label Patients

Identifying health risks and obstacles to treatments can help connect patients with needed behavioral health and community services. But collecting and building population health strategies using Social Determinants of Health (SDOH) is not enough to make health care equitable. Nor is it always used for good.

In fact, SDOH can also be used to label patients as noncompliant or brand them as high risk. Similar labels were used to dismiss patients from practices under financial risk in HMOs. The collection and use of SDOH data must be guided by ethics and accountability in health care, and closely monitored to ensure that discriminatory systems are not set up to eliminate patients.

Likewise, risk stratification and risk factors can lead to misrepresentation of consumers’ real latitude for affecting their health. Obesity, for example, is commonly attributed to choices in diet and exercise, when the reality is much more complex and medical knowledge is still at an early stage.

Where to Start: Look at Data and Listen to Patients

Health care is well equipped to address issues of quality and equity because we are well-versed in commitment to values and measurement of results.  The enormous dedication of providers, the scientific examination of outcomes, and the use of interventions to change behavior and results is understood in health care more than in any other environment. We must look at the data, and always evaluate outcomes in relationship to race, gender, age, and other important criteria that identify patient cohorts. 

Taking responsibility for outcomes goes well beyond the “traditional” past role of providers, where health care services were initiated by patients asking for services, and physicians and health systems responded.  The accountable care movement and Value-Based Health Care have specifically focused on a shift in that provider role.  That shift requires that health care providers take accountability for patient outcomes and introduce better methods to produce better results.  

Health care must envision the opportunities for improving its system, weeding out biases that perpetuate inequities in patient populations. We should honestly examine the processes we use for admitting and guiding patients through our services.  As we expand patient-oriented technology, we must look to all patient cohorts and ask how our decisions will affect affordability, access, and outcomes. 

These priorities are essential to that transformation: 

• See our patients and listen to what they are saying. We can’t assume that poor outcomes are a “fault” of non-compliance when we have not involved patients in constructing a treatment plan that they can manage.
• Promote honest, far-reaching conversations within organizations, including both health care professionals and patients, to identify policies and practices that are embedded in biased assumptions about race. 
• Follow the ample data to identify racial disparities in outcomes. Measures of quality to evaluate health care processes and outcomes sorely need to include race, ethnicity, and gender.
• Refine approaches and interventions to change outcomes, understanding that health systems cannot impose these without transparency and agreement by patients and communities.  There is too much history behind experiments based on race to unilaterally decide approaches without discussion with patients and stakeholders..
• Transparency and inclusion of people of color—patients, communities, researchers, and physicians—are essential to bringing about change. And they must comprise the leadership of such efforts.

Change is hard and has come slowly to health care. This is the moment to catalyze profound transformation of health outcomes for people of color in the United States. Our health care system won’t recover unless we work it out.

CEO and Co-founder of Roji Health Intelligence, Theresa Hush is a health care strategist and change expert with experience across the health care spectrum, including public, non-profit and private sectors.