A Primer on Health Equity 

Addressing health equity is one of the biggest trends in health care today. Health equity is the fair and just opportunity for every individual to achieve their full potential in all aspects of health and well-being. Although the concept has been in play for several years, it quickly rose to prominence in the wake of recent widespread social unrest and the Coronavirus disease – 2019 (COVID-19) pandemic, which once again highlighted disparities in health care access and outcomes for people of color and those living in medically underserved areas.

To be sure, health inequality isn’t new. For years, we’ve seen disparities in outcomes along many dimensions, including race, gender, location, disability status and sexual orientation. However, public and private groups have struggled to address them.
Now the disproportionate impact of the pandemic on people of color reinvigorated the resolve to understand and solve this issue. To that end, today’s health equity movement has added new elements to measure and address disparities by recognizing the impacts of historical and contemporary injustices as well as economic, social, and other community-related obstacles to health and health care, such as food deserts and substandard housing. Health information technology (health IT) will have many roles to play in capturing and sharing these data.

Despite the growing focus, health equity is not just a trend or shiny new thing. The health equity movement is rapidly evolving in both the public and private sectors. Stakeholders have initiated many efforts to learn more about factors affecting health equity and translate those concepts into action. Examples include:

• Top-down organizational support

  Health equity is being embraced by organizations large and small, starting at the boardroom and senior levels. New Health Equity Officer positions have been instituted in C-suites across the country. Organizations are also launching new equity-related initiatives. In health care, examples include the equity initiative recently created by the Pharmaceutical Research and Manufacturers Association, the American Medical Association’s recently launched Center for Health Equity and the American Hospital Association’s new Health Equity Roadmap.

• Federal policy levers

  The federal government has made health equity a priority. Since the inauguration, the Biden administration has brought a “whole of government” approach to equity by issuing a series of executive orders and actions which flesh out its seminal directive on advancing equity in federal agencies and departments. As part of that effort, the administration just released health equity plans for many federal agencies, including the Department of Health and Human Services (HHS).

In addition to its health equity plan, HHS already has undertaken a number of efforts to promote health equity. For example, it established the Office of Climate Change and Health Equity in 2021. Also in 2021, the Centers for Medicare and Medicaid Services (CMS) published its strategic vision for Medicaid and the Children’s Health Insurance Program that named equity as a critical focus area. Equity was also emphasized as a key goal of Medicaid Section 1115 waivers, which give states a mechanism to test alternatives and innovative approaches to payment and services delivery beyond those currently approved.

On the Medicare side of the house, CMS has created a health equity plan based on six high-impact priority areas that encompass both system- and community-level approaches to achieve equity in Medicare. These priorities are being woven into payment and delivery systems. For example, health equity plans are likely to be required in value-based payment models going forward. The requirement will begin in the 2023 plan year as part of the transition to the Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) model, which replaces the Direct Contracting program. CMS is planning to develop ways to improve health equity and performance measures for Medicare Advantage and Part D plans.

In addition, the agency is working to require coverage, payment and risk adjustment based on social determinants of health (SDOH), which are viewed as key measures to evaluate and improve health equity. SDOH are the conditions in places where people live, learn, work and play that affect health risks and outcomes. In fact, Medicare Advantage plans have provided medical benefits as part of CMS’ emphasis on SDOH since 2019. CMS is expected to adopt SDOH measures for risk adjustment and its quality programs.

• Getting the right stakeholders to the table

  As with any initiative, getting the right stakeholders involved is critical. Health equity project stakeholders must include minorities, patients in underserved communities and the undocumented. Gaining participation from these groups may not be easy due to lack of representation in health systems. Moreover, distrust of the government may also hinder participation. Further participation limitations may be caused by the digital divide and unreliable access to technology.
  
  

• Public health infrastructure

  Public health infrastructure should be top of mind when it comes to health equity. Public health agencies are on the front line in collecting and sharing data that identify inequities and enable us to address them. One lesson learned from the COVID-19 pandemic is that the public health infrastructure is old, disjointed and not interoperable — a victim of chronic underfunding made worse by disconnected federal and state policies. Federal agencies and stakeholders are pressing Congress to provide more funding to modernize public health systems; the need is particularly acute among state, territorial, local and tribal governmental health agencies.
  
  Even if funding materializes, there is much more work to be done to revamp technology, both hardware and software. Opportunities include developing interoperable platforms for various kinds of health data, including laboratory data. These must be made available to providers, who often lack access to public health data. Standards also are important. The standards development organization HL7 has recently launched Helios, an initiative for key stakeholders to work together to strengthen the capacity and streamline data sharing of standardized data across all levels of public health using the FHIR standard. Better coordination is needed between federal, state and local governments to eliminate turf battles and data silos.
  
  All that being said, there are pitfalls to be avoided. Stakeholders should not just digitize public health forms and call it a day. They also should be mindful of the analysis measures they are using, which may be flawed. One study found that a widely used commercial health care algorithm reflected a serious racial bias. The risk score calculated by the algorithm used health care expenditures as a proxy for health status. The researchers found that Black patients were consistently and significantly sicker than Caucasian patients with the same score. Training will be needed to support workforce health IT capacity when it comes to health equity; it should not be the first thing cut in the budget.
  
  

• Technology and data sources

  Data-driven approaches will be needed to identify and address health disparities, SDOH and health inequities. Necessary technology and data sources vary by stakeholder group. Each present their own opportunities and challenges.
  • Payers will need to mine data, including unstructured data, to capture these new data elements and data streams. Artificial intelligence and natural language processing will be essential to glean insights. New screening tools will be needed. Few organizations conduct standard screenings for social needs and even fewer have a standardized approach for documenting those needs in the medical record. New or modified electronic health records (EHRs) will be needed to capture this information and share it interoperably with public health, other government agencies and stakeholders. Stakeholders should consider how to collaborate with public health agencies to help aggregate data to meet the needs of all patient populations
  • Remediation may be constrained by difficulties in determining return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. EHRs may need to be enhanced to accommodate documentation and sharing of SDOH data. Medicaid should not be overlooked as a key data source. However, Medicaid has its own challenges in terms of needed funding, interoperability and technology remediation. All of those issues are worsened by the lack of health equity, and it goes without saying that Medicaid patients may be distrustful of the health care system and reluctant to share information
  • Providers are uniquely positioned to collect information on health disparities and SDOH. However, thought must be given to the best mechanisms for collecting the necessary data. Which screening tools are appropriate for a particular practice or facility, as there are many from which to choose? Who identifies patients for screening and when should this occur? Opportunities include physicians, social workers, community health workers, case managers, patient navigators, and nurses. The information can be collected at intake through health risk assessments, screening tools, person-provider interaction and individual self-reporting. How much technology remediation will be needed to incorporate information into the medical record and share it among the care team, other providers and government agencies as appropriate? A bigger challenge will involve incorporating this information into workflows; what will this involve and how can it be jumpstarted?
  • Creating visibility for the invisible. Another major untapped data source is patients who fall below the radar. In many ways, they are at the heart of the health equity problem. Frequent users of the emergency department may incur uncompensated care. There are others who don’t know how to avail themselves of care at all. They could have access but don’t know how or where to obtain it. There are those who just don’t seek care except in a medical emergency, placing unnecessary demand on 911 response agencies. There are language and cost barriers, not to mention a plethora of issues surrounding the undocumented. There are valid reasons driving people to eschew care, and not only people without insurance do so. Payers, policymakers, and providers need to find ways to identify people who are not getting care and understand why. Finding people where they are — such as food pantries and homeless shelters — is one frequently missed opportunity
  • Other data sources, such as Emergency Medical Services data records and Medicaid data, which may be beyond the scope of traditional payer and provider data systems. Some of these systems may be home grown, not standards based, and not interoperable with public health, payer and provider systems