The numbers do not paint a pretty picture of health disparities in the U.S.
“When we talk about racial and ethnic disparities we know, for example, that there’s a 40 percent higher breast cancer mortality rate for Black women or there’s a 10-year lower life expectancy for the lowest income women. There are disparities around maternal health equities, where there are 2-3 times higher mortality rates in Black and Indigenous people than for White people,” said Laurie Zephyrin, MD, Vice President of Advancing Health Equity, The Commonwealth Fund.
Larry Moss, MD, President & CEO, Nemours Children’s Health, made it clear that the issue extends to children’s health care too: “The infant mortality rate for non-Hispanic Black children in the wealthiest country on the planet is double—and in some cases, triple—what it is for White infants. Sudden Infant Death Syndrome occurs in about 85 per 100,000 births in the White population, 190 in Black children and 212 for Native American kids. Non-Hispanic Black kids are almost twice as likely to have asthma and when they have it, they’re five times more likely to be hospitalized. And 75 percent of kids who died from COVID this year were kids of color.”
These stats show the need for health care organizations across all sectors to improve how they use data to close such gaps to reduce disparities. Specifically, organizations must collect, stratify, and regularly review race, ethnicity, language, and sex data (REaLS), say leaders of Health Evolution Forum’s Work Group on Leveraging Data to Improve Health Equity.
As such, the Forum Work Group has received commitments from more than 40 leading organizations to collect REaLS data and then share what they learn to develop best practices that are ultimately disseminated broadly across the industry. Signees of the Health Equity Pledge have agreed to:
- Collect REaLS data for at least 50% of the organization’s patient, member, or customer population
- Stratify and regularly review these collected data by the top-priority quality or access metric for 90% of major business lines and/or departments/divisions of adequate size
- Participate in the Health Evolution Health Equity Learning Lab by sharing stratified data for select measures to facilitate anonymized benchmarking and to identify best practices for reducing disparities
Zephyrin and Moss were joined by Mark Smith, MD, a Forum Fellow and Founding President & Former CEO, California Health Care Foundation, Carrie L. Byington, MD, EVP, University of California Health; Kim Keck, President & CEO, Blue Cross Blue Shield Association, Pat Geraghty, President & CEO, GuideWell & Florida Blue and Tim Suther, SVP & General Manager, Data Solutions, Change Healthcare, on a webcast this week announcing the Health Equity Pledge.
You can’t manage what you don’t measure
There hasn’t been a systemwide effort addressing these disparities, typically because REaLS data has been incomplete in the hands of most providers and hard to access. “What you can’t measure, you can’t manage. Measurement is the necessary action to strategically address these disparities, but our progress in developing and retrieving data is obviously lacking,” Smith said.
According to a preliminary study from the Health Evolution Forum, while 96 percent of responding health care organizations collect some form of patient/member data on race and ethnicity, only 30 percent regularly review disparities based on these data. Moreover, while 70 percent of responding organizations collect patient/member data on language, only 13 percent regularly review disparities in relation to these data.
Indeed, the effort to reduce health disparities through REaLS data has faced numerous barriers in the past, including data classification and integrating it into quality metrics, says Zephyrin. For this reason, she says the third part of the pledge—participation in the Health Evolution Health Equity Learning Lab—is important to helping organizations progress through this journey.
“There’s so much happening in this space around health equity data and desegregating data and new practices that are evolving. We want to try and develop a collection of best practices, so that we can meaningfully institutionalize this structure over time,” Zephyrin says. “I think being part of a community like this where you can hear about best practices and collaborate with each other and learn from what’s happening out there can help organizations move further along this path.”
Byington said that while University of California Health was collecting REaLS data across the system, it was not incorporating that information into its quality improvement infrastructure. For fiscal year 2022, the large system, which has six academic medical centers that care for millions of patients across California, has begun to incorporate REaLS data into its top-line quality goals.
“We have a system wide enterprise data warehouse that collects and curates data from each location’s Epic EHR. Our Center for Data Driven Insights and Innovations, which is led by Dr. Atul Butte, is working with all locations to incorporate REaLS data into our quality data reports. The addition of these data will provide new insights into how the University of California can continue to improve our care for all patients,” Byington said in the webcast. “It will offer us additional opportunities to identify and end health disparities in our health system and state.”
Change Healthcare’s Suther says the company has mapped much of the country’s claims activity to race, ethnicity, language and other non-clinical factors that affect outcomes. The company plans to use this experience—working with numerous health systems—to help push along the pledge effort and provide subject matter expertise to signatories. “This is another way for us to help improve outcomes,” he said.
For two payer-based leaders, using data can identify opportunities to directly connect and work within the communities they serve. Keck at Blue Cross Blue Shield Association (BCBSA) said that after the killing of George Floyd, the 35 Blue plans came together and committed to their own pledge to tackle the issue of health disparities as one example of its work in this arena. Also, the Vaccine Community Connectors program, launched by the Association and AHIP was able to get more than two million seniors in socially vulnerable zip codes vaccinated in early 2021.
“We don’t have REaLS data consistently across our populations, but we have some data that helps us identify the patients at risk. We did the outreach and coordination. We committed to getting rides to members who otherwise would not have had access to the vaccine, or we brought the vaccine to them,” Keck says, adding that the goals of the pledge will allow for the Blue plans to take on even more of these initiatives.
“We’re excited to use the data in meaningful ways to create the right incentives for how we target our interventions and measure our success. We have the goal of reducing racial disparities in maternal health by 50 percent in five years. We won’t be able to do that without the data, so we’re really excited to be a part of this,” Keck added, describing one of the first areas of focus in the Blues’ National Health Equity Strategy, announced earlier this year.
Geraghty at GuideWell & Florida Blue said that the pledge has enabled him to think differently about how the organization reflects the communities it serves. In this regard, he says Guidewell & Florida Blue has created internship opportunities with Historically Black Colleges and Universities as well as entry-level job and skills development opportunities for high school students. The company has also committed $25 million to its equity alliance.
“The more accurate data we have, the better our solutions are going to be, so we’re not just solving for one solution that we try to evenly distribute across our communities. We need to be precise about our answers, and the more data we have that can tell us what is driving the outcomes that we’re seeing, the better our answers will be,” Geraghty says.
The work begins now
While there are challenges, the health care leaders who spoke during the webcast say the work needs to begin now. Smith said that those who say there should be new metrics developed around integrating equity with quality are missing the mark. Instead, current quality metrics should be analyzed and reviewed through an equity lens.
“I can’t imagine there are any hospitals that are not collecting readmission rates at this point. It’s a business imperative to collect readmission rates. If you are not analyzing your readmission rates by ethnicity, principal language or by zip code, you are missing an opportunity to focus your resources on the places where the problem exists and where the inequities exist,” Smith said. “Everyone should take the one or two quality measures that are most important to their business and their work and look at them through the axes that we know contain equity.”
And while there are technical challenges to incorporating REaLS data into quality metrics, Moss was in complete agreement with Smith: “It really isn’t the technical challenge, it’s the will to do it and that’s what is so gratifying about what we’re seeing today. This isn’t complicated, we just need to decide we’re going to do it and commit to it.”