In 2001, the Institute of Medicine (IOM) issued its landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century,
which proposed six aims for improving healthcare quality. One of these was equity: the idea that quality of care shouldn't vary based on personal characteristics like gender, race, ethnicity, or socioeconomic status.
Fifteen years later, progress toward equity has been slow. Racial and ethnic minorities still receive less and lower quality care and experience worse outcomes
across a variety of diseases. The personal costs for these disparities create significant financial and personal burdens. Historically, the financial cost of these disparities has been borne by the public in the form of higher taxes and health insurance premiums. Although significant, this cost was indirect and thereby largely ignored by hospitals and consumers.
Since the passage of the Patient Protection and Affordable Care Act in 2010, the cost of disparities in healthcare has shifted away from the taxpayers and toward hospitals and providers in the form of quality measures.
In order to succeed in value-based reimbursement models, hospitals must deliver optimal performance regardless of the various populations they may serve. Organizations and providers who are aware and understanding of the disparities that exist in their communities and who engage in a culturally competent approach will produce a significant ROI for hospitals through better management of readmissions, resource utilization, and a variety of quality metrics.
Last year, I had the opportunity to contribute a textbook chapter
to Diversity and Inclusion in Quality Patient Care
on addressing racial and ethnic health disparities. In today's blog post, I'll share a few key concepts from that piece, including some suggestions for hospitals.
Health disparities are pervasive and persistent. On average, compared to non-Hispanic whites:
- African Americans die three to four years sooner, with heart disease accounting for much of the difference in mortality. African Americans are also 40 percent more likely to die from stroke, twice as likely to die of asthma, and eight times as likely to die from HIV.
- Hispanic Americans are 65 percent more likely to suffer from diabetes, six times more likely to have tuberculosis, and 2.5 times as likely to die from HIV.
- Native Americans are twice as likely to die of liver disease or cirrhosis, twice as likely to have emphysema, and twice as likely to die from sudden infant death syndrome (SIDS).
- Asian Americans are 15 times as likely to have tuberculosis, 4.5 times more likely to have hepatitis B, and twice as likely to die of stomach cancer.
- Significant racial and ethnic disparities also exist around depression, suicide, infant mortality, obesity, cancer, and kidney failure.
The causes of health disparities are complex. Research shows
that minority populations are less likely to receive certain desirable treatments (cardiac medications, dialysis) and more likely to receive certain less desirable ones (amputation). Socioeconomic factors such as income, education, and insurance status play a role but don't account for all differences. Other possible factors include cultural attitudes, provider competence, availability of care, and the patient's ability to navigate the system.
Health disparities impact all of us. The suffering and disability they cause leave lasting scars on families and communities. Inequity is also incredibly expensive, accounting for up to a third of direct medical costs
among African American, Asian American, and Hispanic American patients. This cost is likely to rise as our society becomes increasingly diverse. (By the 2040s, racial "minorities" will represent half of U.S. population.)
Effects of the ACA
Fee-for-service (FFS) reimbursement is driven by volume, not outcomes. In the recent past, when this FFS dominated the payment landscape, hospitals actually benefited if patients landed in the ED with chronic condition exacerbations. And there was no financial incentive to prevent readmissions or manage resource utilization.
Passage of the ACA in 2010 changed all of that by starting a sea change toward value-based reimbursement. The new law effectively shifted the costs of low-quality care from taxpayers to hospitals and health systems. Today a hospital with high readmissions rates stands to lose tens of millions of dollars in Medicare reimbursement.
Because quality programs directly affect the bottom line, they force health systems to acknowledge disparities within their facilities and referral networks. In order to deliver quality, leaders and providers must understand the mechanisms by which their patients obtain care. For example, it does little good to recommend follow-up to a patient who lives in an area of severe provider shortage.
Cultural competence — behaviors and attitudes that promote communication and trust among cultures — is also important. Notably, culturally competent providers understand the skepticism and preconceptions some have regarding healthcare. For example, some older African American men grew up distrusting physicians, which is understandable in light of medical research abuses like the Tuskegee study
. These patients may benefit from a careful explanation of the reasons for post-discharge testing and follow-up, plus reassurance that their providers truly care about their well being.
What Hospitals Can Do
The number one way that hospitals can begin addressing health disparities is to hire a diverse workforce and one that reflects the communities they serve.
At minimum, the medical and nursing staffs should reflect some of the racial, ethnic, and linguistic diversity of their patients. Given the choice, patients prefer providers
who relate to their culture and tend to report greater satisfaction with such providers. The trust and credibility such an arrangement engenders can add a lot of value to patient care.
Whenever possible, hospitals should hire from the communities they serve. Providers who drive in from the suburbs (or fly from another state) probably won't have a nuanced understanding of local resources and barriers to care. By contrast, an RN from a nearby neighborhood knows where people go for care, what resources are available, and which organizations patients trust.
Another step hospitals can take is to partner with local organizations that embody the community's diversity. This could come in the form of formal care networks and vendor relationships. Some hospitals join community initiatives
aimed at addressing disparities and improving healthcare access. Such partnerships build trust and goodwill while expanding the picture of what great patient care looks like.
Diversity Is an Asset
The benefits of nurturing a diverse, culturally competent workforce were recently driven home to us at CEP America when we were asked to staff the ED at Howard University Hospital (HUH) in Washington, D.C.
HUH was founded in 1862 as the Freedman's Hospital, which provided refuge to ex-slaves. A few years later, it partnered with the Howard University College of Medicine to train African American healthcare professionals. Today, HUH is the only teaching hospital in the nation located on the campus of a historically black university.
So why did HUH choose CEP America, a physician group headquartered on the opposite coast? First, our message was articulated by Pascal Crosley
, who is not only an expert in ED operations but more importantly an established physician leader with a longstanding reputation in this community. As a CEP America Vice President, he represents the diversity that is present throughout all levels of our organization, from the bedside physician to the C-suite
and board of directors
The HUH leadership also noted our long history of treating diverse communities in Chicago, Los Angeles, and Atlanta and the improved outcomes that we consistently deliver for these patients.
Lastly, CEP America has shown great consistency in bringing together a diverse workforce that represents the local communities of the hospitals we serve. CEP already had a positive reputation among D.C.'s physicians. HUH's leadership believed this would help to attract the best and brightest local doctors of the community back to serve at the hospital.
We're thrilled to be partnering with HUH and other likeminded organizations. Such opportunities are made possible because CEP America decided (some years back) to actively embrace diversity. We do this not to be politically correct, but because we believe it's the most effective way to deliver quality patient care.
CEP America is uniquely structured to actively improve outcomes and performance by addressing health disparities. When we combine our experience and understanding, the beneficiaries are our partner hospitals and the communities they serve. There is no more noble cause than that.