After many decades of study and exposition in
the medical and sociological literature, policy makers and
health care providers have finally turned their attention to social
determinants of health (SDoH) and their effects on health outcomes. This is a
welcome development. It brings needed focus on social and economic factors that
play a vital role in how people live, both within and outside the health care
system. These factors include demographic characteristics such as race; and
socioeconomic factors such as education, income, housing, transportation, food
insecurity, and many others according to the World Health Organization.
In addition to the long overdue focus on SDoH,
there is another uncomfortable truth about the scope of bias within the health
care system—about the uneven access, poor quality, and at times nonexistent
care experienced by racial minorities. This
truth was documented by the National Academy of Medicine in a groundbreaking
2002 report, which made clear that medical care can exacerbate the impact of
social factors outside the health care system that lead to poor health,
contributing to even worse outcomes and experiences by minority patients. Yet,
since this report, we have not realized major improvements that address
disparities or improve health equity at scale.
A False Sense That
Inequity Comes From Outside The Health Care System
We are concerned that whether the discussion
is framed around health disparities, health equity, or SDoH, there is a
supposition that social issues exist outside of health care or are hoisted onto
the health care delivery system. Often missing from today’s discourse is the
fact that individuals and communities interacting with the health care system
are subjected to disparate treatment at the hands of clinicians. The popular
press has made this point, with particular focus on disparities in maternal and child
health that have led to persistent and devastating outcomes for
black women and babies. Journalists have dealt head-on with the impact of bias,
racism, and discrimination in and out of the health care system, noting for
example that black women in the highest education, income, and wealth groups
have worse outcomes than white women on the lowest end of the socioeconomic
strata.
The medical literature, too, demonstrates that racial and ethnic minorities and
women are subject to less accurate diagnoses, curtailed
treatment options, less pain management, and worse clinical outcomes. This is true
even within the four walls of the health
care system, when external factors would not be expected to play a
major role.
Behind the data are the personal experiences
and examples of bias and discrimination, which abound in care settings if we
only look or ask. We have personally heard the term “hispanicus hystericus”
applied to Latinx patients with legitimate pain or emotional issues that were
discounted or not addressed. We have witnessed black children not
being treated as children at all, or not being given the same compassion or
level of care—even the use of topical anesthetics—provided for white children.
We have witnessed care teams express frustration with the patients’ cultural
views, such as forgoing blood transfusions or other clinical interventions,
that did not align with “common” or “traditional” views. One of us was
reflexively smacked by a frustrated anesthesiologist while she was in active
labor for not bending down far enough for an epidural.
For many white patients, these kinds of
experiences are inconceivable. But for black or Hispanic patients, maltreatment
can be routine, almost ubiquitous, and those patients are often unable in the
moment to seek redress. Minority patients know they are not being treated well
but have few alternatives for other care.
Medicine and health care act as if we have no
role in producing or promulgating health disparities but instead are simply
responding to them. There may be a certain comfort for medicine in this
approach. SDoH are “external” to the health environment and reflect broader
social factors that largely shield the health care delivery system from direct
accountability. Much of the discussion on SDoH addresses individual
socioeconomic issues that are amenable to policy solutions: transportation
options to ease access to medical care, housing supports to address
homelessness, or prescriptions for food (akin to medical prescriptions). And,
indeed, these interventions address key factors that lead to poor health
outcomes, even in the face of adequate medical interventions.
Implicit bias, by contrast, is “internally”
driven and must be addressed by the delivery system. Acknowledging that
interactions within the health care system can drive poor outcomes is no easy
task and far less amenable to point solutions.
A Reform Agenda That
Faces Up To Bias And Inequity Within, As Well As Outside, The Delivery
System
A true and comprehensive approach to health
equity requires addressing both the social and delivery system factors driving
inequity. We must solve for clinician bias as well as limit the impact of
social and economic factors on health to fully address disparities and better
serve vulnerable populations. Marginalized populations become marginalized
patients through the expression of social factors and delivery system failures.
Our health care system must take ownership of
our contributions to the problem. The reality is that health care is staffed by
individuals who are subjects and purveyors of various social constructs and
beliefs, both positive and negative. Bias and prejudice are as much a part
of health care workers as
in the general population. Moreover, because health care workers are in
positions of authority with the power to exert influence on patients’
experiences, the impact on health outcomes can be significant and long
lasting.
We propose a few solutions that, when coupled
with on-going efforts around SDoH, can help to drive continued gains in health
equity and address factors internal and external to delivery systems. We
envision two main leverage points to address equity: the health care workforce
and the use of data and performance measurement coupled with payment
policies.
The Health Care
Workforce
Bias training. On the first factor, academia and delivery
systems must strive to be better than the current sum of our parts and no
longer reflect some of the greater shortcomings of our society. In the near
term, we should include bias training in medical, nursing, and other allied
health schools, as well as in hospitals and delivery systems. All clinicians
and personnel interacting with patients should receive this training so they
are better attuned to their biases and equipped with skills and tactics to
address them.
Interpreters and translation. We should completely implement basic
standards to promote better communication: interpreters, translation services,
and so forth. These services are often questioned as unnecessary expenses; it
is time to move beyond that discussion and make sure every clinician and care
team can at a minimum communicate with their patients in real time.
Chief equity officers. Finally, we recommend the creation of chief
equity officer roles throughout the delivery system to ensure health equity
remains on the agenda. Chief equity officers are strategic leaders in the
executive suite, with cross-functional oversight of the delivery system’s
performance in serving the needs of patients and customers. We distinguish
equity officers from chief diversity officers, who often focus more on internal
recruiting, retention, and inclusion programs. An equity focus on service and
delivery system performance, rather, will drive an agenda that addresses
internal performance in quality and access for all patients, particularly
vulnerable patients. Chief equity officers would focus on staff training and
accountability and how staff treat all patients. They would also have an
external focus on SDoH and implement approaches that involve broader community
and provider engagement to address medical and nonmedical threats to health
outcomes.
A diversified pipeline. In the long term, we need to dramatically
change our approach to diversifying the pipeline for physicians and other
clinicians. Entrance to professional schools by
racial minorities has stagnated or in some cases dropped at a time when more
diverse physicians and leaders are needed in the country. If programs,
particularly medical schools, are interested in increasing the numbers of
black, Latinx, and other racial minorities in schools, they need to create
relationships with community colleges and high schools to identify students who
may benefit from prompts, coaching, and encouragement to pursue medical
careers.
The costs of medical education are prohibitive
for many students, but they are especially daunting for many students who have
no family or community history on which to base an assumption that they will
earn enough to meet the responsibilities of repaying such significant loans
after medical school completion. Diversifying the talent pool will require
additional investments to defray medical school costs. Some schools have
seen movement in this direction, but more support will be needed, with perhaps
special attention paid to students based on need and membership in underrepresented
racial and ethnic categories. We recognize that racial concordance between patients
and clinicians is not a panacea, but clinicians who share
similar experiences with patients can improve patients’ overall access and
experience with care, feelings of being understood, and consequently, adherence
to improve health outcomes.
Performance Metrics And
Incentives
Beyond addressing the workforce, understanding
health care utilization data and performance outcomes is critical for
addressing health equity comprehensively. Delivery systems and payers should
use all available data to conduct subgroup analyses to determine whether
individuals across demographic characteristics are receiving adequate and
equitable care. These analyses should then connect to quality improvement and
related efforts to address identified gaps and shortcomings. They can also be used
to guide solution development for SDoH, to ensure all equity issues and
interventions are being addressed comprehensively. And as the delivery system
responds to incentives built into the payment system, payment models will need
to reflect a comprehensive approach to equity.
In addition, we recommend the development and
use of specific quality measures to track performance along important equity
outcomes. For many measures currently in use today, stratification along
demographic and other equity-sensitive factors would likely be sufficient to
identify critical gaps. However, new measure development is also required. We
must develop measures to assess implicit bias and inequitable treatment,
whether they are used for accountability programs or improvement efforts.
These measures can be part of standardized,
validated instruments that, for example, assess implicit bias and link to
behavioral change interventions, similar to approaches being taken to address
clinician burnout. There are numerous such instruments designed to assess and
address clinician burnout, such as the Stanford Professional Fulfillment
Index and the Well-Being Index. These instruments assess various
mental states and feelings, sense of fulfillment, and mental fatigue—approaches
that are applicable to identifying implicit bias and the outcomes or actions
that might result from bias.
In addition, we need standardized population
level measures of disparities in outcomes tied both to social determinants and
bias. For example, measures specific to food insecurity could help to identify
at-risk populations, and these measures could cascade to clinical and social
outcome measures tied to equity. (Such measures may involve inclusion of social
risk adjustment models as relevant or necessary.) This would help to ensure
payment incentives are aligned to mitigate and resolve these issues
comprehensively.
Certainly, other solutions may be possible.
Health care cannot be an observer of these issues or continue to suggest that
inequity is produced by broader social forces alone. Our response must have the
urgency this issue deserves. We are reminded of what Martin Luther King, Jr., said
of health inequity: “Of all the forms of inequality, injustice in health is the
most shocking and inhumane.”
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