Addressing Health Inequality

Experts weigh in on how to make healthcare delivery fair game for all populations

In August 2020, the Department of Health and Human Services launched the Healthy People 2030 campaign with an objective of promoting healthy development, healthy behaviors and well-being across all life stages. One of the main drivers of this effort is addressing social determinants of health (SDOH) and health inequities and disparities.

A panel presentation at HealthTrust University (HTU) in August, Closing the Gaps Within Health Disparity: Priorities & Partnerships, showcased what people on the ground are seeing in their communities and what their organizations are doing to combat this issue.

Knowing the score

Health disparities, health inequities, social determinants of health—these are all terms we hear on a regular basis, pointed out HTU panel moderator Aigner George, PharmD, CDE, AVP, Advisory, Pharmacy Solutions for HealthTrust and Chair of the organization’s Diversity, Equity and Inclusion Council. George shared how the Healthy People 2030 campaign defines these terms:

Health inequities: Factors that result in limited access to optimal health
Health disparities: Particular, preventable differences linked to social, economic &/or environmental statuses that create disadvantages in accessing care
SDOH: Conditions in which people are born, live, grow, learn & age that affect overall health & quality of life

Knowing these terms and what they mean is one thing, but do we recognize when these issues are occurring right in front of us each day? And how do we make addressing these issues more than just checking a box?

Darra Edward, PharmD, MSOL/HCM, BCPS, BCCCP

Darra Edwards, PharmD, MSOL/HCM, BCPS, BCCCP, Corporate Pharmacy 340B Program Director for Prime Healthcare System, recalled working as a pharmacy operations manager for a different health system several years back, when she had a revelation about how health disparities impact the delivery of care and patient outcomes.

Edwards became aware of a discharged patient who didn’t get one of her medications returned to her before she left the hospital. Instead of mailing the medication to the patient, Edwards called the patient, an elderly woman who was on both Medicare and Medicaid and living in low-income subsidized housing, and told her she was driving the medication to her apartment.

Checking the patient’s discharge papers, she saw a hospital case manager had done all the right things: arranging for a home health nurse, sending the patient home with a walker and scheduling a number of follow-up appointments with doctors.

But the patient’s meds were jumbled together in a baggie, and she was afraid to take them together, even though the home health nurse had told her to, because she was worried about overdosing. She couldn’t use the walker because her small, one-bedroom apartment was carpeted, and she couldn’t push or lift the walker through the carpeting. And, in regard to follow-up care with multiple doctors’ appointments so diligently scheduled by the case manager? The patient had no idea how she was going to get to them because she didn’t have transportation.

While her medical care, medications and medical devices were all paid for through Medicare and Medicaid, her lack of transportation made her a health disparity case, Edwards said, and the failure of providers to realize that resulted in “a complete miss in the whole process of delivering care.”

“We’re not connecting the dots of why we have the readmission rates we see, because we’re not understanding that some of the interventions we’ve applied to solve the problems are not interventions that are helpful to the particular patients who are actually using them,” Edwards explained.

While knowing the definitions is a simple matter, George said, enacting solutions to achieve health equity is “extremely complex.”

Covering all the bases

Because of that complexity, healthcare organizations are using multipronged approaches to tackle the challenges of SDOH, health inequities and health disparities—and they’re including the care providers themselves.

At Galen College of Nursing, programs are in place to support students, explained Audria Denker, DNP, RN, FAADN, ANEF, Executive Vice President of Nursing at the school, which has its main campus in Kentucky and off-campus instructional sites in 11 states.

“We have a lot of poverty in our student body,” Denker said. “Sixty-five percent of our students are first-generation college students. Providing them with the support and services they need to be successful is of ultimate importance to get them through the program.”

The college looked at why students dropped out and found that about 60% left the program for nonacademic reasons, Denker explained. “We found out some of our students were homeless. They were living out of their cars and coming in and showering or cleaning up in the bathrooms,” she said. Scarcity of food and other resources and lack of transportation were other issues for some of the students.

The college partners with food banks and set up a clothing donation program so students have professional attire to wear to job interviews. The nursing school also partners with workforce investment programs to get funding to help students with the costs of education. A new program that’s just getting started will help students with diapers and formula. “Those are things that you don’t always think about,” Denker said, “but they are factors that can keep students from graduating and finding professional careers in healthcare, which, for some, means climbing out of poverty.”

The college also makes a point of putting its nursing students through poverty simulation training. The students are presented with a scenario, such as if a patient is homeless or just lost their job, the students can learn how complex it is to have to go to the unemployment office or to get food stamps.

“You can just see the light bulbs turn on,” said Denker. They learn that it’s up to them, the healthcare providers, to help get their patients the resources they need, she said.

Playing as a team

For Community Health Systems (CHS), a 70-hospital system operating in 15 states, finding community partners is central to its initiatives countering health disparities and inequities, said Elise Denneny, M.D., FACS, an otolaryngologist with CHS in Knoxville, Tennessee. “Health systems don’t have time to partner with the several resources needed to impact disparity,” she said. “You want one person who is going to be a hub-and-spoke and take care of all these other social resources.”

So, CHS has partnered with organizations such as Knoxville Area Project Access, and through that organization, the East Tennessee Rural Network and the Rural Health Association of Tennessee. These community organizations reach out to food pantries, pharmaceutical and other resources and provide empathetic education to residents in need.

Within its own hospitals, CHS medical staff are encouraged to evaluate their patients to identify SDOH or health disparities prior to discharge, so any needed adjustments can be made before a patient leaves the hospital. “I try to challenge every physician when they discharge someone to do a double check,” she explained. “Let’s look at what other health-related social needs this person’s going to have that could impact or be a barrier to a good outcome.”

Prime Healthcare’s 44 hospitals in 14 states also depend on community partnerships to help address SDOH, health inequities and health disparities. “We operate from the standpoint that the community as a whole has a vested interest in this,” said Edwards. “There are many local entities that already have infrastructure in place that can help support building these relationships within the community and with patients.”

To become a trusted entity before a healthcare issue brings someone to a hospital, Prime Healthcare has actively sought out partners in the places where community members have frequent contact, such as:

Places of worship
Schools
Municipal government
Ethnic/cultural organizations
Governmental agencies
Professional/business organizations
Property management companies

Many of these partnerships lead to downstream benefits, such as being able to use the partners’ physical spaces as health clinics for community members. Partnerships with schools can create an employment pipeline thanks to new, directed apprenticeship programs, for example. “It allows you to have those touchpoints just by collaborating with all of the different entities,” Edwards added. And when you report back to them about the successes resulting from these collaborations, your partners see the value added to the community, and they continue to afford you greater access—bringing it full circle in order to meet the needs of the community.

Looking within

While the external community is often the focus of healthcare organizations’ efforts to address SDOH, health inequities and health disparities among their patients, the HTU panelists agreed that administrators also need to look within the walls of their own hospitals.

There are hospital employees who leave their professional jobs at the end of the workday to go to other jobs, she pointed out. And hospitals have employees who face housing insecurity, are on public assistance or burn out because they’re working multiple jobs to make ends meet.

If healthcare organizations are willing to devise meaningful training and remediation based on the understanding that SDOH, health disparities and health inequity are internal as well as external, Edwards concluded, “then we can be a lot more compassionate, not just to the community outside our four walls, but to the community that’s within our hospital as well.”

Health Inequities & the Impact on Maternal Morbidity & Mortality Rates

The United States is one of the wealthiest countries in the world, and yet, its maternal morbidity and mortality rates are among the worst. The Centers for Disease Control and Prevention (CDC) says that more than 80% of pregnancy-related deaths are preventable. What can be done to improve these statistics?

Frank Kolucki, Jr., M.D., FACOG

“We are so blessed to be in America, and we have all these incredible resources and technology,” says Frank Kolucki, Jr., M.D., FACOG, Chairman of Obstetrics and Gynecology at Moses Taylor Hospital in Scranton, Pennsylvania, and HealthTrust Physician Advisor. Still, “the maternal mortality rate in America continues to be an abject failure. This is particularly tragic and concerning for Black women, American Indian women and Alaskan native women, because their rates of maternal morbidity and mortality are significantly higher.

“The U.S. death rate for maternal mortality was 10 per 100,000 in 1990. What’s shocking is that in 2022, when we have some of the most recent data, it’s 32.9 per 100,000,” explains Dr. Kolucki. “The rate for non-Hispanic Black women rose from 37.3 to 69.9, and it increased 2.6 percentage points for non-Hispanic white women. The rate of death is 3.3 times higher for Black women and 2.5 times higher for American Indian and Native American women.”

Many women are put at risk because of social determinants of health and healthcare disparities and inequities, Dr. Kolucki explains, such as financial struggles, housing and transportation issues, lack of exposure to adequate education, food insecurity, issues of safety, mental health and addiction challenges.

Racial bias also contributes significantly to the risks women of color face during pregnancy, delivery and in the year following birth, Dr. Kolucki notes. “There is a plethora of examples in the press and in the medical literature where women are not heard, they’re not believed and they don’t get the appropriate care,” he says. “This can happen to anybody, but, unfortunately, it happens disproportionately to women of color.”

Mikio Nihira, M.D., MPH

Another factor that contributes to high maternal mortality and morbidity rates is poor reimbursement rates, stated Mikio Nihira, M.D., MPH, medical director for Seven Star Medical Group in California and a HealthTrust Physician Advisor. “It has everything to do with money,” he said.

“Medicaid deliveries are loss leaders, and labor and delivery units in general are loss leaders for hospitals because of poor compensation,” he explained. “Not surprisingly, if you’re doing a lot of business in a population that doesn’t pay well, you’re not going to want to provide that service. That’s just the bottom line.”
Since maternity departments are losing money for hospitals, these units are being shut down all over the country, but especially in rural communities, creating maternity care deserts, he said. “This becomes a major problem for the community because where do these people get care?”

Because of the many factors playing into the United States’ poor maternal mortality and morbidity rates, improving those rates must be tackled on a variety of fronts, said Drs. Kolucki and Nihira. Some possibilities for making incremental progress include:

Increasing reimbursement rates. In terms of reducing maternity care deserts, Medicaid should pay higher reimbursement rates for maternity care & women’s health services in general.
Creating policy. States & the federal government should move to enact policies & regulations that disincentivize hospitals from closing their obstetric departments.
Educating providers & patients. Providers need to have some training & introspection to make sure that they’re treating all the patients with the same respect that everyone deserves. And patients need education on healthy living, prenatal care that supports pregnancy & the supportive options available after giving birth.
Increasing mental health resources. Providers need to address mental health conditions in a way that will positively address health disparities & improve outcomes before & after pregnancy.

To learn more about what your organization can do to address social determinants of health, health disparities and health inequities, visit the American Hospital Association Institute for Diversity and Health Equity.