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When Blue Cross and Blue Shield of Minnesota began work to address racial and health equity, CEO Craig Samitt, MD, wanted to lead by example. So the first step was assessing the presence of systemic racism within its own walls. The expectation was that prevalence would be low because BCBS MN is a large and well-paying health insurer. Instead, Samitt described the results — which came from a survey, KPIs and other metrics of performance — as a humbling and heartbreaking experience.

“We had a representation problem. We were not a diverse organization. We found that we had an inclusion problem,” Samitt said. “Even worse, we had a pay disparity problem and the most heartbreaking thing of all is we found that we had a major social determinant of health problem: some of our associates were concerned about where their next meal would come from or whether their housing situation was stable and some of our associates had trouble affording our own insurance.”

Samitt, who left BCBS MN in May 2021, is credited as being the first Blues CEO to state that racism is a public health crisis. BCBS MN in February 2021 also donated $5 million to the University of Minnesota to build the school’s Center for Antiracism Research for Health Equity. And CDC Director Rochelle Wolensky, MD, in April 2021, “declared racism a serious public health threat.”

While problems that result from systemic racism are common in organizations across many industries, they certainly create substantive obstacles for health care entities.

“Diversity, equity and social determinants of health are the most fundamental issues and drivers of health or lack thereof,” said Alexandra Drane, Co-Founder and CEO, ARCHANGELS. “There is no more foundational element to humanity than to care for others and to be cared for ourselves.  In order for that care to happen, we need to foundationally address diversity, equity, inclusion and the social determinants of health.”

Assurance and equity start at home
Within the workforce, improving health assurance starts with creating cultural concordance, enabling health literacy and encouraging a work-life balance.  

“Equity starts at home by addressing systemic racism, assuring representation, tackling the things that get in the way of a true inclusive and authentic culture and thinking very differently about benefits and pay,” Samitt said. “Frankly, for me and for all of us, this is the hardest of the hard issues.”

Yet, striving for equity can improve the bottom line. In its oft-cited 2019 research, McKinsey & Company found that enterprises with greater gender diversity financially outperformed those with less diversity by 25 percent, while ethnically diverse executive teams outperform others by 36 percent. And the consequences of not pursuing assurance and equity can inhibit an organization in other ways as well.

“If you don’t take care of yourself and the people who are providing care in your organization, they cannot provide good care,” said Cheryl Pegus, MD, EVP, Health and Wellness, Walmart. “We know from a lot of the research that’s been done on health equity that it requires cultural concordance. be it in rural or urban communities.” 

Pegus added that cultural concordance is one of the reasons she elected cardiology as a specialty. “People need to see people like them to feel as if they understand their experiences. Care is more than a procedure or prescriptions, it’s understanding the components of health that occurs when you are not in the doctor’s office.” 

Health care leaders also must include a focus on health literacy within the workforce and the community as part of the initiative as well.

“Health literacy sometimes gets minimized. It is at a fifth-grade level based on initial IOM work. That work actually showed even college educated people are at a fifth to seventh grade level of understanding health information,” Pegus said.  

An important aspect of health literacy is acknowledging that the pandemic has been an incredibly stressful time and encouraging employees to step back from work, take appropriate breaks, turn off the video for meetings when it becomes too much pressure and to focus on sleep. Pegus said CEOs and other executives should set an example by taking such steps themselves.

“People want to hear from me that I not only step back, but I am encouraging them to do so as well,” Pegus said. “What I would love is to see everyone come back to me and tell me how that’s working out too.”

Equity outside the organization
BCBS Minnesota realized that as a health plan and as a payer of both clinicians and suppliers, it could pivot to reward people for making assurance and equity a priority.  

“We paid differently for wellness, prevention, community, social determinants of health,” Samitt said. “Our hope was that our community would act differently. That’s the intent of our work.”

Samitt pointed to food insecurity as one example of the social determinants of health that can be addressed by joining forces with outside organizations in the community.

“If we create a coalition of the willing, including all health plans, all businesses, all care delivery organizations, and we collectively said, ‘We’re going to stamp out hunger in Minnesota.’ That is a tangible action we can take to solve the hunger problem in Minnesota,” Samitt said.

Establishing coalitions simultaneously creates the opportunity, and the need, to reconsider community relationships.

Drawing a distinction between working to bring the member or patient population into your facilities and engaging in proactive outreach on the community’s terms, Pegus pointed out that discussions about equity need to focus on going into the communities to ensure people have a trusted partner who listens and understands their journey to effectively support their wellness.

Starting assurance and equity work internally, then expanding outward will require executives to lead difficult conversations. Samitt describes them as “brave” while Pegus applies the term “fierce” to such discussions.

“Are we being safe? Or are we being brave?” Drane added. “Nothing is going to change if we’re just sitting around being safe all the time.”

Samitt added that when leading these discussions, it’s important to keep in mind that equity is not about treating everyone the same, rather, equity is about offering everyone an equal opportunity to live a long, healthy, sustainable life — and achieving assurance will require collecting feedback from the workforce and community.

“Our job is to really listen well and ensure that the people who are doing the work feel that we’ve given them the right tools and to make sure that the people sitting around our table represent the communities that we serve,” Pegus said. “That’s how we’re doing it. That’s how we’re working on it.”

For BCBS, leading by example ultimately means demonstrating that its leadership could take steps to move the organization in the right direction, Samitt said.

“The problem is big,” Samitt said. “My hope is that if we do this, and every corporation does this and every community does this, then we will begin to truly see traction addressing racial and health equity.”

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Tom Sullivan

Tom Sullivan brings more than two decades in editing and journalism experience to Health Evolution. Sullivan most recently served as Editor-in-Chief at HIMSS, leading Healthcare IT News, Health Finance, MobiHealthNews. Prior to HIMSS Media, Sullivan was News Editor of IDG’s InfoWorld, directing a dozen reporters’ coverage for the weekly print publication and daily website.