The way we talk about and address the topic of health equity is actively changing. We took the opportunity to speak with Joe Betancourt, MD, MPH, Director of the MGH Disparities Solutions Center, and Deputy Director Aswita Tan-McGrory, for an update on the latest developments regarding where this area of health care may be headed in the near future.
How would you define “health equity?”
Joe Betancourt: You can break up that definition into two parts. One is health care service, ensuring any patient who walks through our doors receives the same quality of care no matter who they are, regardless of race, socioeconomic status, or sexual orientation. Additionally, from a communications standpoint, it’s showing that there are no differences in health outcomes—for example with conditions such as diabetes or cancer—when looking at different populations.
Can you speak to the evolution of health equity in recent years?
Betancourt: In the 1980s there was a great deal of attention placed on the fact that there were demonstrable disparities in health outcomes—or that there were issues related to health quality, more generally speaking, among minority populations. This was especially true as it related to the biggest killers, such as diabetes and cancer. These findings started a national conversation, which was later re-energized by the Clinton Initiative on Race, which fundamentally changed things for the underrepresented. We now had a blueprint for targeting and monitoring the nation’s health, called Healthy People. It was through this initiative in the early 2000s, which demonstrated that people with the same level of insurance, comorbidity, and other identical factors still received a different quality of care based on ethnicity. Most recently, in last 10 years, we have come a long way towards a better understanding of the root causes of these health disparities. Now, the most important part of the conversation is unsurprisingly related to health care reform and transformation. As we move toward value, there is real understanding that we cannot achieve goals without a focus on equity.
Today, there’s an intense focus on the concept of “social determinants of health.” What is the relationship between health equity and this concept?
Aswita Tan-McGrory: Social detriments apply to the environments people live in, and the resources they have available to utilize. The reason for that intense interest today is that a traditional hospital would not have a particular focus on this area of a patient’s life. These are detriments that affect people outside the hospital doors, but even so there’s been a realization that we need to go further upstream. There’s been a realization that a patient who has been cared for, but is then sent back to an isolated environment with no amenities, (no refrigerator for a medication, or transportation for a follow-up visit) will likely have to come back to the hospital within 30 days. The way that we’re addressing this is to partner with community organizations outside of the hospital that are already working on these accessibility issues, and who are not solely focused on health care institutions, but also instances when patients are returned to their homes after receiving care. These are not skills that a clinician can or should do, but it’s been demonstrated now that it’s a contributor to better outcomes, and that we do need to partner with the community organizations that offer these services.
One of the biggest issues providers face in effectively addressing inequities in health outcomes are related to data—both lack of data and poor data quality—especially when it comes to data on social determinants. Are we making progress on these challenges?
Tan-McGrory: I think we’re making progress in that organizations are recognizing the need to collect data. However, the challenge is always going to be implementation. The other piece of the challenge is what data do you collect? There is a lot of information for identifying social determinants of health. Who should collect the data is a challenge. Should I be a social worker, a clinician? And then how does one integrate that data into the current workflow. We’re at the beginning stages, but there’s definitely awareness. The Center for Medicaid Services (CMS) Center for Minority Health has put out compendium on data collection, specifically regarding race and ethnicity and how to collect disability. This is a signal to the rest of us that this is becoming important.
Betancourt: There’s an understanding that data collection and implementation is going to be very important. There’s also an understanding that we need to know how characteristics such as ethnicity, language and social class interact with health care. So there’s a great deal of effort put into collecting measurable data. However, once we’ve collected it, we need to have the bandwidth to do something about it. The next stage in the data evolution is how to use data findings to make a difference.
Tan-McGrory: Organizations are certainty developing innovative ways to capture data. Blue Cross Blue Shield put together a mapping tool, and CMS has also done something similar.
There is a lot of talk right now about this being a time where clinical care, in the form of population health management, and public health in the form of addressing social determinants, are aligned. Given that, what are you most hopeful about with regards to the future of the health care in the US?
Betancourt: The good news is that in just this past month, there was a paper released by Health Affairs demonstrating that they’ve identified how Blue Cross Blue Shield, through a value-based payment program, improved the quality of care for those who are wealthy as well as those from lower economic statuses. They also were able to narrow disparities between these two groups. We’re certainly seeing results and signs that positive changes are becoming a reality. That said, this is still a time of great volatility in terms of access to care. We maintain real concerns about health care access. The issue of value and how to pay for health care is going to continue to be a real concern, but we’ll continue to move and make progress in equity. I think we are very fortunate that our center has been able to leverage MGH’s leadership nationally. Out of that experience, we’ve created a sustained movement. We’ve trained over 300 individuals in 31 states. Partners HealthCare now has a new Equity of Care committee, driving initiatives forward with the leadership of Tom Sequist, MD, MPH, who is the Chief Quality and Safety Officer at Partners HealthCare. Today, we’re seeing Partners replicating the work that we are doing at all of its institutions.
Tan-McGrory: I’m hopeful that the last 8 years have seen real and demonstrable momentum in health care. I hope that, despite recent changes and potential changes, that momentum will continue to drive through the next 4 years. Everyone’s on board with this now, we have the focus, and even if things change at this point, that focus will not go away, because we now fully understand why access is so important.