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Chronic diseases pose an acute and growing challenge for the United States’ health care system. According to the CDC, approximately six in 10 U.S. adults have a chronic disease, while about four in 10 U.S. adults have more than one chronic disease. These conditions—including Alzheimer’s disease, diabetes, cancer, chronic kidney disease, chronic lung disease, heart disease, hypertension, obesity, stroke, and others—are among the leading causes of disability and death in the United States and drive much of the country’s annual health care costs. Research suggests the number of U.S. adults with chronic conditions will continue to increase in the coming decades, which could further exacerbate the monetary, health, and life costs of these diseases.

While chronic diseases can affect all Americans, data show disparities between rates of chronic conditions among different demographic groups. For example, America’s Health Rankings in its 2023 Annual Report noted that, “[i]n 2022, the prevalence of multiple chronic conditions significantly varied by disability status, age, race/ethnicity, income, geography, educational attainment, veteran status, gender, and metropolitan status.” Specifically, the report stated that prevalence of multiple chronic conditions was higher among American Indian/Alaska Native adults, at 17.8%, and multiracial adults, at 15.6%, than Asian adults, at 3.4%. Prevalence of multiple chronic conditions also was higher among women, at 13.1%, than men, at 9%, according to the report.

To help address this intensifying problem, supporters of Health Evolution’s Health Equity Pledge, which was developed by the Roundtable on Data-Driven Health Equity Strategies, recently convened to discuss strategies for preventing and optimizing care for chronic conditions, with a particular focus on identifying and combating disparities in chronic disease care. Roundtable Co-Chair Kelli Tice, MD, VP of Medical Affairs and Chief Health Equity Officer at GuideWell & Florida Blue, moderated a discussion with Mark Gwynne, DO, President of UNC Health Alliance, and Michael Uchrin, CEO & Co-Founder at Monogram Health, on how health care organizations can lead in this space.

Data is Key

Gwynne, Tice, and Uchrin said it’s crucial that organizations collect and stratify data on chronic conditions in their patient populations by race, ethnicity, language, sex, sexual orientation, and gender identity. “We believe that by using the right data from the right sources, we can assess the populations we serve, understand what changes may be needed, and implement solutions in order to advance health equity,” Tice said.

However, it can be difficult for organizations to collect that data. Health Evolution recently conducted a survey of our Health Equity Pledge supporters to gather insights about demographic data capture and experiences in addressing disparities in chronic conditions. The survey showed there is opportunity to increase identification and measurement of chronic conditions by race, ethnicity, language, sex, sexual orientation, and gender identity across organizations’ patient populations. Specifically, survey respondents noted that adopting data collection and stratification of patients’ sexual orientation and gender identity is particularly challenging, with data on these identifiers largely captured on a voluntary and inconsistent basis.

Recognizing this challenge, the discussion leaders shared strategies for increasing demographic data capture.

For example, Gwynne said throughout the Covid-19 pandemic, UNC Health found that “by setting system priorities and using its decades’ worth of data and operational infrastructure, and by prioritizing a systemwide focus on reducing disparities,” issues surrounding demographic data capture and stratification “were not unsolvable.” When starting out, UNC Health realized its “data were imperfect and there were large gaps in race, ethnicity, language, and other types of demographic data,” Gwynne said. But that “inspired” UNC Health to implement “a broad educational program and initiative to encourage its very frontline staff—such as registration folks in emergency departments, ambulatory clinics, and other sites of care—to ask new questions” to patients, Gwynne explained. In addition, UNC Health taught staff how to be more comfortable with asking patients for information about their gender, race, sexual orientation, and other demographic details, Gwynne said.

According to Gwynne, that campaign led UNC Health to see “marked improvement in data collection,” which enables the organization to “apply demographic information across every measure that we look at and then visualize” where gaps exist and need to be addressed.

Monogram Health also uses demographic data to identify care gaps and areas for improvement, Uchrin said. To ensure the organization is advancing health equity, Monogram recognized it had to “move beyond looking only at the retrospective metrics” of hospitalization and readmittance rates and focus on collecting data around “race, ethnicity, language, sex,” and more to understand where there were “opportunities for high-value, evidence-based clinical interventions” to address disparities, Uchrin explained. Having those metrics available for clinicians “in real time” enables Monogram to intervene more effectively and move the organization’s health equity initiatives forward, he said.

Be Proactive

Increasing demographic data capture not only helps organizations identify and address gaps in the moment, but it also allows them to take a more proactive approach to combating disparities, the discussion leaders said.

Improving data collection helped UNC Health to build the infrastructure and capabilities needed for the organization to systematically identify disparities “across populations, geographies, conditions, and utilization,” which UNC Health used to drive physician engagement through a quality improvement approach, Gwynne said. Using data as a guide, UNC Health “built quality improvement collaboratives among its providers in primary care, urgent care, cancer care, cardiovascular care, pediatrics, and now increasingly behavioral health and hopefully maternal health over the next couple of years,” Gwynne explained.

As part of those collaboratives, UNC Health “focuses on an array of quality measures broken down into achievable targets, and we really support practices across the state in achieving those targets,” Gwynne said. For example, Gwynne explained, UNC Health tells its “teams that we’re no longer interested in improving colorectal cancer screening from 90% to 91% across the entire population, but what we’re very interested in is reducing this disparity between our BIPOC and white populations for colorectal cancer screening by 20%.” By taking that approach, Gwynne said, “we increase our overall performance to 91% or 92%.”

In addition, UNC Health has “engaged with hospital leaders across the state to choose a health-equity focused measure as a targeted organizational goal, and each hospital has to engage in a health equity dashboard for at least one specific measure,” Gwynne said. “There’s real power in shifting our quality focus to reducing disparities,” he noted.

Approaches like these can help organizations move more upstream in addressing disparities and prevent patients from “falling off the cliff of good health,” Tice said. “We have to be willing to capture the proper information, and then analyze that information properly, to identify patients in need before they get to the cliff,” rather than “standing at the bottom of the cliff, waiting to catch them,” she noted.

Adjust Care Delivery to Truly Address Patients’ Needs

But ramping up data collection and proactively analyzing gaps is not enough. Organizations also must transform the way they’re delivering care in ways that truly address patients’ needs to diminish disparities, the discussion leaders said.

Uchrin said that, “to truly transform care, Monogram had to start with understanding the characteristics of our patient population” and then consider whether the organization’s care model “had the right capabilities to take on meeting patients’ care-plan goals and be effective in serving underserved populations.” During that analysis, Monogram recognized it needed to provide multi-specialty care to adequately serve patients. Uchrin explained, “We needed to be a nephrology practice from the ground up that was more akin to a multi-specialty practice so that we could not only treat patients’ kidney disease, but also their hypertension, their endocrine issues, as well as end-of-life and geriatric palliative care for those with end-stage comorbidities.”

Further, Monogram determined that it had to operate “in and around the communities of our patient populations” and reflect the patients the organization serves, especially to effectively provide services in patients’ homes, Uchrin said. He noted that Monogram hires clinicians who “live and are from those communities” and who “look like and have a tremendous understanding of the cultural norms” of patients in those communities, which helps ensure that the organization’s providers can better engage with patients.

At UNC Health, the organization “dedicates population health resources and capabilities to support interventions at the front line with our care teams and communities in ways that are meaningful and measurable,” Gwynne said.

UNC Health also works with payers to incentivize care practices that focus on reducing disparities. “There are real dollars in our value-based contracts for improving performance across populations. This focus on disparities can really drive overall performance and allow us to invest in community engagement, practice engagement, and more to advance health equity,” Gwynne said. For example, Gwynne noted that UNC Health is involved in a pilot program with Blue Cross Blue Shield of North Carolina in which the organizations “together designed financial incentives to focus on diabetes, hypertension, and colorectal cancer screening for specific populations to reduce disparities by an agreed upon target.”

Health Evolution’s Health Equity Pledge

Executives participating in the discussion touted their commitment to and involvement with Health Evolution’s Health Equity Pledge as a driving force behind their organizations’ efforts to advance health equity. “We’re so committed to health equity and the Pledge because we believe, at its core, there’s no other way to transform care delivery for those with late-stage chronic kidney and end-stage kidney disease,” Uchrin said.

As a response to the challenge of addressing health disparities, Health Evolution Forum launched the Health Equity Pledge to meaningfully strengthen data foundations through the collection, stratification, and review of race, ethnicity, language, and sex data, with the ultimate goal to more effectively identify disparities, diagnose root causes, and instill accountability for eliminating them.

These actions, structured into three Pledge objectives, are a significant opportunity to embed equity into quality improvement and interventions across the health care industry, and to reduce disparities in care delivery, the patient and member experience, and outcomes.

To date, more than 50 health care organizations have signed the Pledge.

Learn more about the Health Equity Pledge.

Thank you to our Health Evolution Community and Partners

Health Evolution would like to thank members of our Roundtable on Data-Driven Health Equity Strategies and our Health Equity Pledge supporters for contributing to this work.

Health Evolution also would like to thank AmeriHealthCaritas, Optum, and MetaCX for their partnership in supporting this work.

Ashley Antonelli

Senior Manager, Executive Communications

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