Charting the Course Toward More Equitable Healthcare Systems

Healthcare equity remains an elusive goal for health systems across the county.¹ In a recent report,² the Commonwealth Fund highlighted persistent disparities in healthcare outcomes across all fifty states. Black, Latinx/Hispanic and American Indian and Alaskan Native subgroups continue to be at higher risk for morbidity and mortality related to treatable conditions like diabetes and cancer. In addition to exacerbating these disparities, the COVID-19 pandemic illuminated structural factors within the health system that hinder progress, including lack of physician diversity, variable quality in translational services, bias in algorithms used to identify patients at risk and inadequate partnerships with community leaders and organizations to address social determinants of health.^3–5

Previous efforts to address health inequities focused on improving access to high quality care for historically marginalized groups under the assumption that a “rising tide lifts all boats”. However, in real world settings, the connection between process of care (e.g., A1c testing) and clinical outcomes (e.g., blood sugar control or Hemoglobin A1c) is complicated by factors within and outside of the health care system.⁶ For example, among insured adults in a large integrated health care system, we reported racial and ethnic disparities in adherence to antihypertensive medications that were partially mediated by patient socioeconomic status, physician prescribing behavior, and type of drug coverage (e.g., copay amount).⁷ As a consequence, focusing on processes of care alone is unlikely to eliminate disparities in our health care outcomes.

Achieving an equity focused healthcare practice will require several steps. These steps include improving the collection of accurate patient race, ethnicity and language data,⁸ speeding the adoption of equity-focused quality improvement measures,^9–12 and the design and dissemination of effective interventions to address social needs.¹³ To achieve equity goals, we need to move beyond current quality improvement strategies. A critical step is the development and adoption of equity-focused measures of care quality.

In the August 26^th online issue of Medical Care, Becket and colleagues¹⁴ evaluate the real-world performance of one such metric, the Health Equity Summary Score (HESS).^15,16 Developed by the Centers for Medicaid and Medicare Service Office of Minority Health,^15–17 HESS is a standardized metric designed to identify and evaluate healthcare disparities. Developed using patient experience measures from the 2016–2019 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),¹⁸

HESS enables the assessment of variance in patient experience by race, ethnicity and dual Medicare and Medicaid eligibility.^15–17 HESS facilitates equity measurement at a point in time or over time within a single health system, as well as comparisons of equity across hospitals. These measures can be used internally by health systems to track progress toward equity goals, as well as by payors to incentivize the prioritization of health equity goals.¹⁶

While HESS is not the only health equity measure available to health systems, it was ranked highest in a contracted study conducted by RAND and sponsored by ASPE’s (Assistant Secretary for Planning and Evaluation) Office of Health Policy.¹⁷ Beckett and colleagues report notable correlation between the HESS and the organizational and financial characteristics of hospitals.¹⁴ They also note a high degree of correlation between the HESS and overall quality scores. However, as previously observed, high average quality scores sometimes masked important differences in outcomes by race, ethnicity and preferred language. Using the HESS measure, Beckett and colleagues provide yet more evidence that place matters, with Black, Hispanic, and non-English language preference patients being more likely to receive care in low performing hospitals.¹⁴

The authors demonstrate the potential utility of HESS and similar measures in clinical practice. Beckett and colleagues also report important limitations to its immediate application in practice. For example, 56% of hospitals in the HCAPS were excluded from the analysis due to insufficient survey responses from relevant subgroups. This limitation is likely a reflection of suboptimal data capture within health systems and inadequate systems to support data capture.^19,20 Fundamentally, these data gaps are a direct result of an ongoing racial divide in care delivery, where health outcomes are largely determined by where patients receive care. Understanding these structural factors is critically important for interpreting the results equity focused quality metrics.

As we strive to move health systems toward a more equitable future, we will need to see additional innovations in metric development. For example, how will HESS and other metrics account for intersectionality and structural racism and perceived discrimination?^21–23 In addition, how will social needs and health system factors be assessed to lend interpretation to equity gaps that persist over time? Further, health systems and payors will need guidance to minimize the potential for the use of these metrics to select patients for care exclusions or exclude Providers who are more likely to serve patients at high risk.²⁴ This next stage of the work, while necessary, is perhaps the hardest as it requires thinking beyond individual systems to the broader healthcare ecosystem and the external environment.

However, health systems do not have to tread this path alone. Partnerships between health systems and patients and community organizations can facilitate the prioritization of needs and the further development of metrics that matter. Moreover, community partners can aid in the interpretation of data findings and in the development of guidance regarding the appropriate use of these metrics.²⁵ Ultimately, if these metrics are to guide clinical practice, patient and community organizations will be critical partners in the design of interventions to address drivers of disparities within and outside of the health care system.