How to uncover and address inequities in health care

January 6, 2020

When Christopher Holliday speaks about the inequities in health care that plague our society, one word comes up over and over again: avoidable.

As huge and systemic as the inequities in health care outcomes can seem for different segments of the population, they are ultimately avoidable, according to Holliday, PhD, MPH, who serves on Capella University’s School of Nursing and Health Sciences Advisory Board.

But Holliday is not naïve. He knows rooting out those inequities is a complex, ongoing struggle, and not simply a moral dilemma to be bemoaned. Disparities in the data demonstrate this. For example, African Americans have a mortality rate from heart disease that is 27 percent higher than white Americans. And among households that earn $25,000 or less annually, the mortality rate is more than three times that of households that earn $115,000 or more.

Beyond the moral and social justice reasons for striving for equity in health care, there is also a strong economic incentive to reduce inequities. Poor health outcomes for marginalized populations can lead to increased costs for health systems, insurers, employers, and patients. The economic burden of health disparities in the United States is projected to increase to $126 billion in 2020 and to $353 billion in 2050 if the disparities remain unchanged.

Dig into the data

The manifestations of disparity in health care may be easy to see (such higher disease or mortality rates), but the specific causes can be hard to identify in day-to-day care and are often hidden in the data. Holliday gives the following example.

In his role as director of Population Health & Clinical-Community Linkages with the American Medical Association, Holliday is helping to lead an initiative to reduce uncontrolled high blood pressure among African-American men, who are disproportionately affected by the condition. By digging into the data regarding the treatment of this population and the resulting outcomes, it has been determined that African-American men are prescribed one or two separate drugs to treat high blood pressure, and not always according to clinical guidelines. They could realize better blood pressure control by receiving a single pill with a combination of medications. 

“Just collecting accurate race and ethnicity data can be incredibly effective in identifying inequities,” Holliday explains. “When health care professionals have access to accurate and reliable demographic data, they can evaluate, for example, hypertension control rate outcomes stratified by race, gender, sexual orientation, geography, you name it, to surface disparate outcomes by a group. This allows you to then address specific issues. They might end up saying, ‘I thought I was treating everyone the same, but this group is clearly seeing less favorable outcomes compared to other groups.’”

Recognize that everyone has unconscious bias

Ironically, one of the obstacles to achieving equity in health care outcomes lies with health care professionals who believe they are not biased.

“I don’t care how opened-minded you are, we all have biases,” Holliday says. “We may believe strongly that we are not bigoted, but the truth is implicit or unconscious biases are simply part of our makeup as human beings. It’s important to recognize that. For health care professionals who believe they hold no biases at all, the urgency to look for disparities in the care they deliver can become less urgent. After all, they believe they are not the problem, so they don’t have to do anything to address the problem. Well, we all have work to do. Everyone.”

Holliday adds that health care professionals who say, “I’m color blind,” or, “I don’t see the differences in my patients; I treat them all the same,” can actually do more harm than good. 

“It’s simply not helpful to ignore or refuse to acknowledge the unique circumstances and realities of patients and their lived experiences, whether that is based in race and ethnicity, gender identity, sexual orientation, or income level,” Holliday says. “It’s important to see all of these differences, and to recognize what those patients are dealing with and how that can impact their health outcomes.”

Go beyond the hospital or clinic walls

Even when health care organizations and professionals understand the moral and economic implications of addressing disparities in care, trust the data, have come to terms with their own unconscious biases, and have made combatting health care inequities a strategic priority, disparate health care outcomes in their patients can and do persist. Why?

The reality is that achieving positive health outcomes is just as dependent on what happens outside the hospital or clinic walls as within.

“There are so many factors that affect a patient’s health beyond the direct care they receive at a hospital or clinic,” Holliday says. “The neighborhood they live in. Their access to transportation. Their proximity to healthy food options. Community safety.  All of these things and more impact a person’s ability to be healthy.”

To address those outside factors, Holliday is a strong advocate for screening for a patient’s social determinants of health to surface issues, such as housing or food insecurity. He is also a big believer in care extenders or patient navigators, such as community health workers. They are trained to culturally and linguistically translate health-related information to patients, whether in the clinic, home, or neighborhood setting. They can help make sure patients truly understand what they need to do to be healthy and have access to community resources to help them accomplish that.

“Community health workers are key in helping to solve for health care disparities,” Holliday says. “They essentially help patients navigate the broader health care system. By creating robust linkages to community resources, they can be incredibly helpful in reducing health disparities.”

Health literacy among some patients is also often lacking. The solution goes beyond simply making sure hospital signage and brochures are written in multiple languages, for example. It’s also about making sure that what is said to a patient and what is written in discharge instructions or a medical report is provided at a literacy level that the patient can understand and is communicated in a culturally and linguistically appropriate way.

“Sure, you may have a brochure describing risk for type 2 diabetes translated into a patient’s native language, but do they really understand it?” Holliday says. “How do you know? Did you ask? Getting confirmation of understanding is so important. People have wildly different educational levels and abilities to comprehend oftentimes complex medical information. We need to take the time to make sure they understand and can act on the information.”

In summary, Holliday feels good that significant progress has been made in addressing inequities in health care. He says health care organizations are paying increased attention to the issue, as is demonstrated by the rising number of top health care leaders with titles such as chief diversity officer or chief inclusion officer or chief health equity officer.

“We still have a long way to go, but the good news is that there are a lot of people and organizations paying attention and making health equity a priority,” Holliday concludes.

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