Editor’s Note: As the country reemerges from a pandemic that has had a disproportionate impact on communities of color, Academic Medical Centers (AMCs) are shifting out of crisis-response mode and reflecting on opportunities to intentionally promote equity, advance anti-racist policies, and bring science to bear on the challenge of eliminating health disparities in access to and outcomes of care. In a new white paper, summarized below, Manatt Health describes strategies in nine areas of focus that can position AMCs to be leaders in eliminating disparities in their organizations and their communities:
- Mission-specific strategies (Education, Research and Clinical Care)
- Internal strategies (Leadership and Governance, People and Culture, and Data and Analytics)
- External strategies (Purchasing Power, Community Partnership, and Policy and Government Relations).
In addition, the white paper includes a slide pack highlighting successful initiatives around the country. Click here to download a free copy of the full paper and slide pack. Click here to view our free webinar sharing how AMCs are implementing health equity action agendas—within their organizations and in partnership with their communities.
Background
Pillars of clinical care delivery, medical research and education, AMCs have a complicated history when it comes to health equity and structural racism. They are major contributors to their communities, often serving as safety net hospitals, partnering with community clinics to serve the indigent, reinvesting in local communities through community benefit initiatives, and shedding light on health disparities through research initiatives. Yet, like all health care stakeholders, AMCs are complicit in the structural racism that exists in our health care ecosystem.1
AMCs have considered health equity within the purview of their community benefit programs. By taking a more expansive view of opportunities to advance health equity—across all missions, internal policies and external relationships—AMCs can begin to unwind some of the structural inequities in access to and outcomes of care. However, they are part of a larger ecosystem with highly inequitable health insurance coverage and reimbursement structures—and those must also be addressed to achieve a vision of true health justice.
Mission-Specific Strategies
Education Mission: Shaping the Providers and Culture of Care of the Future
a. Invest in Educational Pathways (often referred to as “pipeline programs”): AMCs can invest in programs that support minoritized populations in building up the foundational science and academic skills required to pursue a higher education in health care.
b. Bring an Equity Lens to the Admissions Process: As with workforce recruiting efforts, the admissions process can be subject to bias and should be reviewed to ensure that eligible diverse candidates are included for consideration.
c. Support Underrepresented Minorities in Funding Their Training: AMCs should be deliberate in setting up policies and programs that support diverse candidates in starting and completing their training.
d. Bring an Equity Lens to the Curriculum: AMCs must review their curriculum and training processes to proactively dispel false beliefs about biological differences between black people and white people to avoid perpetuating undertreatment and mistreatment that result in health disparities. Cultural humility and implicit bias training should also be embedded in the curriculum to ensure future providers are equipped to effectively treat patients from culturally, linguistically and socioeconomically diverse backgrounds.
e. Support the Retention and Advancement of Diverse Faculty: For AMCs, like many organizations, diversity rates decline at the higher echelons of the organization. Medical school faculty are predominantly white males, especially so at the professor and associate professor ranks. AMCs should take deliberate action to diversify their faculties and create an inclusive culture that supports their retention.
Research Mission: Advancing the Knowledge Base on Effective Strategies to Eliminate Disparities
a. Invest in the Science of Health Disparities Intervention: Dedicated research centers are critical to bringing to light the disparities in access to and outcomes of care and designing and implementing interventions in collaboration with the communities impacted in order to eliminate these disparities and advocate for changes to their structural root causes.
b. Engage in Community Trust-Building Activities to Achieve Greater Diversity in Clinical Trials: Many AMCs seek clinical trial participation rates that are representative of their general patient populations and communities served, but without doing the hard work of engaging with the communities to foster greater trust, these numbers are likely to remain unchanged.
c. Engage in Community-Based Participatory Research and Codesign: Best practices include engaging community in all stages of the research process, including defining the area of inquiry early in the design stage, and closing the loop with community stakeholders to review research findings.
Care Delivery Mission: Dismantling Inequities in Access, Quality, Experience and Outcomes of Care
a. Embed Health Equity Metrics Into Quality Improvement Strategy: The first step for advancing equity is collecting data—starting with Race, Ethnicity and Language data (REAL)—and establishing a set of metrics that are useful and reflective of the AMC’s specific areas of disparities.
b. Eliminate Race-Based Adjustments That Have No Medical Basis in Clinical Decision Support Algorithms: There are examples in cardiology, nephrology, obstetrics and urology, and likely others, of “race-based medicine” rather than “evidence-based medicine”—that is, where racial adjustments are made that suggest black people presenting with the same symptoms as whites are at lower risk for certain conditions. AMCs should be at the forefront of using data to test the assumptions that are baked into clinical decision support guidelines and redesign those that have no empirical basis.
c. Bring an Equity Lens to Care Delivery Processes and Access Strategies (sites of care strategies, payer contracting strategies): This is likely the hardest strategy to implement as it pits an AMC’s desires to advance health equity against its need for financial growth and sustainability. In trying to implement this strategy, the limits of an organization’s capacity to overcome structural racism manifest themselves. Bringing an equity lens to care delivery strategies entails asking whether access and capital expansion strategies inadvertently reinforce health inequities, implementing deliberate strategies to promote greater access to care for under-resourced communities, investing in bridging the digital divide in virtual care strategies, and taking a balanced portfolio approach to growth. Importantly, it is also in their role as advocates for coverage and reimbursement policy change that AMCs can influence the structural market dynamics that entrench inequities in U.S. health care.
d. Screen Patients for Unmet Social Needs and Connect to Community Resources: Many of the social factors that lead to poor health outcomes—such as poverty, housing instability and food insecurity—are the result of systemic racism and economic policies that have historically marginalized communities of color and prevented opportunities for wealth creation. Health systems can play a part in connecting people in need with social service and community-based resources.
Internal Strategies
Leadership and Governance: Setting the Tone for Combating Structural Racism and Advancing Health Equity
a. Define and Affirm the Importance of Health Equity for the Organization: Boards of directors and boards of trustees play a critical role in defining the organizational and performance priorities of leadership. Board trainings and expertly facilitated conversations are an important place to drive a unified vision of the board’s role in advancing equity and articulating the nature of that commitment.
b. Adjust Performance Dashboards and Compensation Models to Promote Equity: By requiring that diversity, equity and inclusion (DEI) and measures of health disparities be part of the performance dashboard—alongside traditional financial and quality indicators—the board can signal its commitment to advancing equity and holding management teams accountable for progress.
c. Diversify the Board and Leadership Teams: AMCs with more diverse boards are better positioned to understand the needs of the communities being served, promote greater trust with those communities, and consider the impact of organizational strategies on black, indigenous and people of color (BIPOC).
d. Ensure Leaders of Equity Initiatives Are Appropriately Recognized and Resourced: Several black faculty have shared their stories of stepping back because of the unrealistic expectations placed upon them to lead diversity initiatives while having full research, teaching and clinical care commitments.2 It is critical to have dedicated and resourced leaders while also embedding equity into the culture such that it is considered everyone’s responsibility.
People and Culture: Building and Supporting a Diverse, Culturally Competent Clinical Workforce
a. Strengthen Diversity Recruitment Efforts: AMCs should review their recruitment strategies and pipelines for ways to connect with diverse candidates. Setting quantitative targets can help drive change, but attainment is only meaningful if the diverse hires feel safe, included and able to grow their careers.
b. Enhance Diversity Retention and Leadership Development Programs: There are a variety of strategies that can support greater retention and promotion of diverse talent, from creating expertly facilitated affinity groups to instilling a culture of mentorship to appropriately resourcing Diversity, Equity and Inclusion initiatives to updating the review process to recognize diverse staff for leading diversity efforts.
c. Shape the Culture Through Mandatory Training and Facilitated Conversations on Cultural Competency, Humility and Implicit Bias: Physicians often harbor false beliefs about biological differences between black people and white people. These false beliefs, unchecked, lead to very real differences in health outcomes, and AMCs must ensure they are not perpetuated within their walls.
Data and Analytics: Measuring Progress and Community Impact
a. Refine the Data Collection and Reporting Tools to Support Goal Setting and Tracking of Equity Measures, in support of:
- Embedding health equity metrics into quality improvement strategy (Care Delivery Strategy)
- Adjusting performance dashboards and compensation models to promote equity (Leadership and Governance Strategy)
b. Harness the Power of Big Data, Artificial Intelligence (AI) and Machine Learning (ML) to Root Out Bias in Health Care: AMCs are at the leading edge of using Big Data to develop algorithms for more rapid diagnosis and treatment. The value of Big Data analytical tools depends on the data used to train them, and algorithms trained on inaccurate, poor-quality or nondiverse data will yield erroneous results and reinforce biases in care delivery.
External Strategies
Purchasing Power: Embracing the Anchor Institution Role to Build Community Wealth
a. Establish Requirements and Targets for Hiring Locally: By making a commitment to hiring and training local community members to serve in skilled labor roles in the health system, AMCs can achieve the dual objectives of meeting their workforce needs and enabling community skill and wealth building.
b. Work With Local Vendors and Minority-Owned Businesses: Public institutions, including state-funded public university health systems, have been leading the way in building into their procurements more explicit requirements that vendors have diverse teams and/or be women- or minority-owned businesses. Private AMCs can follow suit.
c. Partner With Other Anchor Organizations in the Community to Align Wealth-Building Initiatives: As an example, in Chicago in 2017, major academic, county, and community health systems and community clinics formed a collaborative called West Side United to coordinate community engagement and build community health and economic wellness. To date, the collaborative has coordinated $6.5 million in impact investments into Chicago’s West Side.3
From Community Benefit to Community Partnership: Building Long-Term, Bidirectional Trusting Relationships
a. Develop Partnerships With Community-Based Organizations to Address Unmet Social Needs. By assessing unmet social needs and connecting patients to community resources, AMCs can support upstream solutions that can mitigate the downstream impacts on health they encounter when patients present in their clinics and emergency rooms.
b. Engage in Codesign With Communities to Address Issues Identified by Community Needs Assessments. The Affordable Care Act (ACA) requires all nonprofit hospitals to submit a community health needs assessment (CHNA) every three years. Some AMCs have approached this requirement as a “check the box” exercise, while others have used it as an opportunity to partner with Federally Qualified Health Centers (held to a comparable requirement) to work collaboratively with their communities to define needs and design solutions.
c. Invest in Social Drivers of Health (SDOH) Programs and Measure Impact. Some health systems are investing directly in the built environment that impacts health outcomes in their communities—ranging from sidewalks and street lamps to promote safe exercise, to housing to address homelessness, to farmers’ markets on-site to provide access to healthy food options.
Policy/Government Relations: Advocating for Equity-Driven Policies
a. Advocate for Universal Coverage. Health coverage is a necessary first step in promoting access to care but on its own is not sufficient. Despite gains in health coverage thanks to the ACA, racial and ethnic disparities in health access, care and outcomes persist even when controlling for socioeconomic status (e.g., education, income).
b. Advocate for Equitable Coverage Design. Every single health policy has the risk of reinforcing structural racism. AMCs should urge state and federal policymakers to bring an equity lens to coverage design policies by looking closely at the data on whom their programs cover, as well as access and outcomes metrics by racial, ethnic and other demographics to surface potential biases.
c. Advocate for New Reimbursement Models That Support Equitable Care Delivery. Ideally, moving to value-based payment over the past ten years would have promoted health equity, but there’s evidence that it did not.4 Health equity must therefore be a more explicit objective of reimbursement policies.
Conclusion
By implementing a broad-based health equity action agenda, AMCs can lead the way to a more just and equitable delivery system. Importantly though, direct action must also be coupled with advocacy for changes to the structural policies that ingrain racial inequities into the health care delivery system. Until more equitable access to health insurance and more equitable reimbursement policies are secured, AMCs can mitigate, but not eliminate, disparities in access to and outcomes of care.
1 For more on the topic of complicity, see Dr. Mark Smith’s address, “What Can We Do to Help?”
2 For examples, see:
3 West Side United, “Our Impact,” https://westsideunited.org/our-impact/ (Accessed June 21, 2021)
4 Joshua M. Liao, MD, MSc, et al., A National Goal to Advance Health Equity Through Value-Based Payment, JAMA. June 4, 2021. A National Goal to Advance Health Equity Through Value-Based Payment | JAMA | JAMA Network