Building a more equitable health care ecosystem is what keeps me engaged in our improvement world. Our primary organizational strategy at FHCQ is “applying an equity lens to build shared accountability for progress.” Equity as a concept feels omnipresent – I hate the idea of equity as jargon or worse – a commodity. I find that people use obtuse language when they don’t know what they are talking about or don’t want you to understand what they are talking about. A step to de-jargonize is to make sure we have a shared understanding and shared vocabulary and then have the tools to make necessary changes. The Centers for Disease Control and Prevention define health equity as every person being able to “attain [their] full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health potential is fascinating to me – how long we could live and how well we could live, all of us – not just those of us born in zip codes that all but guarantee wealth and health.
COVID – for all the pandemic has done – has been elevated in the national dialogue our need and desire to address inequity in health and health care. We can look at differences in life expectancy and disease burden by minoritized group such as by race as a starting point – for black men life expectancy is 4.7 years lower than white men and for black women 3.3 years lower than white women due in part to higher rates of heart disease, cancer, homicide, diabetes, and perinatal complications. Black women are three to four times more likely to die in pregnancy, childbirth, or the postpartum period compared to while women. I believe that we can change this disparity, add years to life for black women and men by illuminating these gaps, changing clinical practice including eliminating unequal processes within clinical care, and constant improvement. A recent op-ed by thought leaders at McKinsey goes further and calls on us all to add life to years on a global scale – while life expectancy has increased globally (54 years in 1960 to 73 years in 2019) the proportion of life that people spend in poor or moderate health remains unchanged; in both cases about half of our life is spent having one or more acute or chronic conditions that impact quality of life or impacts our daily activities.
An equity lens is then is our “process for analyzing or diagnosing the impact of the design and implementation of policies on under-served and marginalized individuals and groups, and to identify and potentially eliminate barriers.” This is us stratifying processes and outcomes by race, sex, sexual orientation, language, class – and using the tools that we have to close these gaps – like targeted universalism is our policies, like reducing implicit bias in clinical care, like understanding how women present with heart attacks in emergency departments. The Blue Cross Blue Shield Association calls for cross-sector collaboration around health equity data to (1) develop and adopt data collection and exchange standards across Race Ethnicity Language (REL) and Sexual Orientation Gender Identity (SOGI) data sets while continuing to build standardization for Social Determinants of Health (SDoH) through the Gravity Project, (2) develop and adopt standards for sound imputation methods and use of health equity data, and (3) learn from patients how best to collect REL, SOGI and SDoH data an provide transparency to patients on how such data will be used.
The Centers for Medicare and Medicaid Services have proposed adopting a “Hospital Commitment to Health Equity measure” in the Hospital Inpatient Quality Reporting Program for 2023. This will “assesses a hospital’s commitment to establishing a culture of equity and delivering more equitable health care by capturing concrete activities across five key domains…strategic planning, data collection, data analysis, quality improvement, and leadership engagement.” This is a good step – an acknowledgement that for too long our delivery systems have been rooted in inequitable care delivery on top of an inequitable society.
So, forgive me English teachers – I am going to use equity as a verb (my action word) – the north start that we at the FHCQ will revisit and redo until we build this better system.