Electronic Health Reporter

By Karen Conway, vice president of healthcare value, Global Healthcare Exchange (GHX).

The cost of healthcare disparities has been long and deeply felt by patients and their families, but it wasn’t until the high rates of COVID-19-related hospitalizations and deaths among persons of color made headline news that the broader societal impacts of health disparities became more widely known.  In response, health systems are prioritizing health equity and leveraging new tools and data to support their work.

At a physiological level, the presence of underlying chronic disease increases the risk presented by COVID-19. The incidence of chronic disease(s) is increasing among all Americans, but the prevalence is much higher among the poor, which includes a higher percentage of individuals of color compared to the overall White population.[1] Health inequities among communities of color are further exacerbated by structural and institutional racism, which experts say “harms health” because of negative factors in their physical, social, and economic environments and a propensity to develop maladaptive coping behaviors (e.g., smoking, alcohol, etc.)[2].

A Community-Level Issue

Increasing rates of chronic disease create a self-reinforcing cycle that threatens the well-being of entire communities (and the health systems that serve them). Individuals suffering from chronic disease have higher rates of absenteeism,[3] which limits their wealth building potential, the productivity of their employers and the tax base of their communities. This, in turn, increases poverty and the impact of the social determinants of health (SDOH) that contribute to higher rates of chronic disease. The combination of chronic disease (as an inflammatory condition) and the psychological stress of racism have been shown to cause physiological changes that raise the risk of contracting additional chronic diseases.[4]

Hospital performance is also tied to economic well-being. Research documents a correlation between the quantity and quality of local economic resources and the clinical performance of hospitals, which under value-based payment models, can also impact financial performance.[5]  With chronic disease responsible for nearly 90% of national health expenditures,[6] it’s continued rise threatens our national economy and the ability to fund needed healthcare for the poor and aging. In other words, this is not just a social issue; it is an economic imperative. A 2021 Institute for Healthcare Improvement (IHI) study found that 58% of healthcare executives ranked health equity as one of their organization’s top three priorities, up from 25% in 2019.

Supply Chain Solutions

One way to address health equity is through the supply chain. Today, healthcare providers are leveraging the supply chain to increase their impact on local communities by purchasing locally, and training and hiring from the communities they support.

Rush University Medical Center, which cares for patients living in impoverished communities on Chicago’s west side, is exemplary in its approach to improving health equity by tapping into the purchasing power of its supply chain. It all began with the health system’s 2016 Community Health Needs Assessment (CHNA), which identified structural racism and economic deprivation as the root causes of health disparities, including higher rates of chronic disease among those living in the city’s west side neighborhoods. That prompted the Center to elevate health equity as a strategic objective and to focus efforts on addressing the SDOH factors contributing to those disparities.

Recognizing the power and responsibility of anchor institutions, Rush was one of the founding members of the Healthcare Anchor Network (HAN), which seeks to build sustainable, local economies that foster, not hinder, health. HAN’s work focuses on three primary areas: local impact purchasing, community investment and hiring. As Rush and other HAN members have demonstrated, supply chain can support all three areas.

For years, hospital supply chain departments have documented their spend with certified diverse suppliers. More recently, those same institutions have sought to direct more of their purchasing to diverse organizations that operate and hire locally.

In some cases, supply chain organizations can create those hiring opportunities. Using Rush as an example again, it chose its new distributor partner, Concordance, based on its offer to build a distribution center on the city’s west side and to hire and train 75% of the workforce from the community. More recently, Rush partnered with the Tullman Foundation and InUrban Strategies to train individuals from disadvantaged neighborhoods for supply chain roles and to guarantee interviews to those completing a training program.

Local community investment is also critical to building communities and health equity.

Another funding member of HAN, Toledo-based ProMedica has focused its efforts on the needs of the downtown core, where higher rates of obesity were tied to a lack of affordable, healthy food. ProMedica opened a grocery store in the area to provide more nutritional and employment opportunities. Supply chain has played an important role in the market’s success, through its purchasing power and relationship with its prime distributor Sodexo.

Data-driven Techquity

Data is increasingly recognized as key to the success of these health equity initiatives. The same 2021 IHI study referenced above found that 55% of health systems executives are working to capture equity-related patient data, including race, ethnicity, ancestry, language, sexual orientation and gender identity. More than 1,600 hospitals have also signed the American Hospital Association #123forEquity Pledge to Act, which includes a commitment to increase the collection and use of race, ethnicity and language preference data. Meanwhile, the Robert Wood Johnson Foundation (RWJF) has created a first-of-its-kind national commission to study what is needed to create a data infrastructure to support health equity. The commission’s blueprint for change endorses the principle that our data systems must provide indicators of the health harms caused by racism and other forms of discrimination and the evidence to eliminate these inequalities.

At the heart of this work is a recognition that health equity is increasingly contingent upon the quality and accessibility of technology, or what is known as “techquity.” Low-income patients often lack the digital infrastructure needed to take advantage of expanding digital health offerings, such as the broadband for virtual visits. Data can help health systems identify and target the unique needs of specific patients. That data is best incorporated in electronic health records, where clinicians and social care providers can review the range of factors that contribute to a person’s health status.

An often-underutilized resource are the Z-codes that are part of the ICD-10 coding system used to document diagnoses and procedure data for patients. Z-codes specifically address factors related to the SDOH, including exposure to racism and other negative psychosocial factors. Beyond Z-codes, HL7, which works to support interoperability among EHRs, launched the Gravity Project to further enhance the standards used to document SDOH data related to “food insecurity, housing instability and quality and transportation access.”[7]

Manufacturers, meanwhile, are working to increase equity in clinical trials, beginning with ensuring products are tested by a more diverse population. Historically, clinical trials have included a higher percentage of white, male patients.[8] By ensuring more diversity in clinical trials, manufacturers can better evaluate the ability of products to address the needs of specific patient populations.

Achieving Health Equity

While current financial constraints are leading some health systems to slow their movement toward a value-based system, more strategic organizations recognize that addressing health equity is critical to their long-term financial viability.

We can only move the needle on health equity by capturing and analyzing data about the degrees of disparities, the populations impacted, the root causes and the effectiveness of specific interventions. Unlike episodic acute care, chronic disease develops over time, and many of the issues that affect individual health (e.g., structural racism) have deep, historic roots. While it will be harder and take longer to measure the impact of these interventions, they are critical to the health and wellbeing of so many – from patients and their families to local communities and health systems to the national economy.

[1] https://www.cdc.gov/pcd/issues/2021/21_0086.htm

[2] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30569-X/fulltext>

[3] Scandinavian Journal of Work, Environment & Health – The relationship between chronic conditions and absenteeism and associated… (sjweh.fi)

[4]  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428178/ 1

[5]  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2893955/ 7

[6] Health and Economic Costs of Chronic Diseases | CDC

[7] https://www.hl7.org/gravity/>

[8] Diversity & Inclusion in Clinical Trials (nih.gov)