Tom Sullivan | August 5, 2020
Prior to COVID-19 many health care organizations were working to address social determinants, including racial disparities, and focusing on ways to improve care for underserved populations.
“Social determinants of health effect the poor in terms of access to fresh food, safe and affordable housing, job training and education,” said Paul Tufano, Chairman and CEO of AmeriHealth Caritas. “Social determinants can impact up to 80 percent of somebody’s health outcomes — so when you put the lens of the pandemic on top of that, it just makes it much more complicated.”
Tufano hosted the Health Evolution virtual gathering Confronting Racial Disparities and the Drivers of Health During COVID-19. Joining him in the webcast were Wright Lassiter, III, President and CEO, Henry Ford Health System; Hal Paz, MD, Chief Executive Officer at Ohio State Wexner Medical Center; and Laurie Zephyrin, MD, Vice President, Health Care Delivery System Reform, Commonwealth Fund.
“Health system leaders and policymakers may want to throw up your hands and say, ‘You know what? All this is going on outside the health care system. What am I supposed to do?’” said Zephyrin. “For corporate leaders expressing the need to address racial inequity, there are ways to start on this journey.”
During the virtual gathering, in fact, the experts discussed issues that CEOs can address to strive toward a more equitable system:
Understanding the scope of inequities
Henry Ford Health and OSU Wexner have been ranked among the top four organizations by Forbes Best Employers for Diversity; the other two are SAP and Procter and Gamble.
Describing Detroit as both having a history of challenges and today being “a city that is a majority minority,” Lassiter began with some statistics.
African Americans encompass 14 percent of Michigan’s citizens but represent 40 percent of the deaths since March. What’s more, of the 10 million people in the state, Detroit has 670,000 residents and Lassiter said as of June more than 75 percent are African Americans. During the pandemic, Detroit has had 12,000 cases and some 1,400 deaths. Lassiter added that Detroit had 60 percent of cases and 75 percent of deaths across the state.
In OSU Wexner’s territory around Columbus, Ohio, Paz said a correlation exists between predominantly Black communities and neighborhoods, even those in relatively close proximity to OSU Wexner. Profound issues arise from social determinants, including multi-generational families in which one or more members have a job that may not be adequately protected from COVID-19. “It’s poverty, it’s education, it’s transportation, it’s housing, it’s food deserts,” Paz said.
Broadband is another prominent challenge. Although it is available across the city of Columbus, for underserved populations that lack adequate hardware to engage virtual visits, ubiquitous broadband does not help.
“We’ve seen this story over and over again, and we know that this correlates with certain underlying behavioral determinants of health,” Paz said. “We see this confluence of social, behavioral, environmental determinants of health that have a profound impact on these communities in particular.”
Recognizing why health disparities exist
Taking Detroit and Columbus as just two examples, the natural question to ask: Why?
“The short answer is because those communities had greater incidence of socio-economic and educational challenges,” Lassiter said. “As a result, those are the populations that will have greater incidence of lack of access to do the things that we know influence health outcomes.”
In addition to the health harms of COVID-19, Zephyrin pointed to the widespread economic and social disruption that has been severe overall, but particularly severe for Black, Indigenous and People of Color. Zephyrin cited recent data from the Census Bureau that found more than half of Black adults and about two thirds of Hispanic adults have experienced loss of income, while 20 percent of Black households report not having enough food in the last seven days.
“When we think about where these disparities arise, as a result of systemic inequities, that effect where people live, where people work, where people play, their ability to access health care, and the social stressors that are experienced, we need to understand the structural issues,” Zephyrin added. “Many people of color are disproportionately represented in essential work settings, such as health care facilities, farms and factories.”
The reality that many people of color also live in geographical regions with higher rates of pollution adds to the complexity.
While that is by no means a complete history of health disparities, Zephyrin said recognizing that what is unfolding during COVID-19 is the “compounding of existing inequities” that have come under the spotlight in 2020.
Learning from successful anti-racism programs
OSU Wexner was one of the first academic medical centers to create and implement an anti-racism strategy.
“The initial step was to acknowledge and address dismantling racism and inequities in OSU Wexner’s own systems. Here. At this institution. And to declare early on that racism is a social determinant of health,” Paz said. “Sometimes we don’t talk directly about these challenges. We thought here at our institution, it was incredibly important to do that.”
Next, OSU Wexner translated its anti-racism values and affirmations into actions, with the goal of driving engagement to improve education policies and practices. That included determining how to fund the program within OSU as well as making that funding transparent to the larger community in a manner such that OSU Wexner is held accountable to the expectations it hopes to achieve.
Paz continued that it was exceptionally important in OSU Wexner’s anti-racism action plan to engage and equip employees, faculty, staff and students with the tools they need to participate in anti-racism actions in the community, and broadly across the state. And to empower them to actually address racism, poverty, and other social determinants of health wherever encountered.
“We wanted to create roundtables against racism, where we bring together a diverse group of individuals at the institutional level with the community, to talk about how we implement this strategy in a very measurable and transparent way,” Paz added.
From there OSU Wexner began conducting implicit bias training because that can be an unconscious barrier in advancing diversity policies as they are incorporated into day-to-day operations. The point was to ensure the policies are put into action, rather than just residing on a static piece of paper.
“We focused on elevating our commitments to creating a diverse and inclusive workforce,” Paz said. “That’s just a framework to launch forward, not to self-congratulate.”
Working with government — but taking politics out of public health
The pandemic inspired sweeping regulatory changes — to telehealth, reimbursement, state licensure, even HIPAA relaxations to a certain extent — that have at the very least offered a glimpse into what could potentially become a more equitable and efficient health care system.
“Government has a huge role, particularly in crafting policies. With Medicaid, for example, there have been a lot of opportunities to help with access to care during this pandemic. Being able to allow states the ability to expand eligibility or freeze premiums … that’s the potential role of policies that are specific and impact vulnerable populations,” Zephyrin said. “It’s important to craft policies with the health equity framework in mind.”
Ensuring that the federal funding being disbursed is targeted to communities of color is also critical, Zephyrin added, as is helping providers serving communities of color.
Lassiter added that ideally the current politicization would be taken out of the public health discourse, reimbursement would not just be focused on doing something to a person to generate revenue, and health care would be broadly distributed across the country on an equitable basis.
“Those three things would go a long way to helping the United States get beyond where we are, which is still a bit of an embarrassment when it comes to public health,” Lassiter said. “They would improve our ability to ensure that the 330 plus million citizens of this country have access to equitable health care and to be able to live their best lives.”
Tufano seconded the notion of taking politics out of public health.
“The pandemic is really bringing even further to light these issues in terms of the people who we serve and the opportunities we can make,” Tufano said. “The power to fund is incredibly impactful and where the funds go, what you expect in terms of outcomes, you really can drive change that way.”
Preparing the workforce for lasting pandemic impact
“Post traumatic shock syndrome.” That’s Lassiter’s term, and concern, for the industry given how so many clinicians have been placed on the front lines of COVID-19. A common scenario is a clinician holding a phone or tablet so a patient’s family, prohibited from an in-person visit, can say goodbye.
“You have caregivers now being a surrogate family member,” Lassiter said. “That is certainly dramatic. Normally in hospitals we don’t experience a ton of deaths.”
The pandemic is taking a significant toll on the emotional well-being of almost everyone by interrupting daily life, creating economic hardship and social isolation, Tufano said, and casting a cloud of fear that we or our loved ones will get sick and die.
“Such uncertainty can trigger issues of well-being, including substance misuse, self-harm, depression. It is a traumatic time, and while trauma can affect anyone regardless of socioeconomic status, we know that low-income families or those living in poverty may be at greater risk of long term emotional and physical health consequences,” Tufano said.
That is equally true among the community and health care and social care workforces as it is the general population.
“The challenge that we’ve seen amid COVID-19, is fragmented social care workforce and the importance of scaling and investing in that community,” Zephyrin said.
Within those challenges, however, is the opportunity for executives to partner with organizations in the community to strengthen workforces.
Zephyrin noted that AIRnyc quickly scaled its social care providers by equipping them with technology to continue meeting the needs of vulnerable New Yorkers. The COVID Rapid Response Coalition is another example of a community-based organization leveraging technology and pulling together CEOs with clinical and social services.
“Bringing together community-based organizations under a hub that’s continuing and building partnerships is something that has a lot of opportunity to leverage their strengths across communities,” Zephyrin said.
The intersection of an unprecedented pandemic, an economic crisis and, of course, racial and societal issues that have come to the fore in the past several months has sparked a recognition that many health care enterprises can play a unique role in their communities, states and at the national level.
“It doesn’t matter what part of the health care industry you’re in. It could be on the provider side. It can be on the managed care side. It can be on the policy side,” Paz said. “All of us can play a role.”
Ultimately, the problem of social determinants and racism are bigger than health care and, instead, permeate all industries and many aspects of life — and leading health care CEOs are already thinking beyond the industry itself.
“Health care as a whole can provide much needed leadership on this issue,” Tufano said. “But none of our organizations are going to be able to eliminate disparities on our own. We have to work together.”
Watch the Confronting Racial Disparities and the Drivers of Health During COVID-19 webcast here: