A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.
“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.
”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”
That’s because the social determinants of health – diet, inactivity, substance abuse, poverty, and more – “account for nearly 75% of disease,” said Kevin Smothers, MD, FACEP, vice president and chief medical officer at Adventist HealthCare Shady Grove Medical Center in Rockville, Md. “Health care providers are only able to ‘fix’ about 15 percent of the causes of poor health.”
A report recently published by the University of California, San Francisco, and the Robert Wood Johnson Foundation (RWJF) takes on the definition of health equity.1 Because, as one of the report’s authors, Paula Braveman, MD, MPH, professor of Family and Community Medicine and director of the Center on Social Disparities in Health at UCSF, argued in a Health Affairs blog post in June 2017: “Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.”
Measurement is an unavoidable aspect of the practice of medicine in the 21st century and both Dr. Fitterman and Dr. Smothers say hospitals must start focusing on the nonmedical factors that influence health to find success.
“Payment reform is forcing delivery reform,” Dr. Fitterman said.
A report from the National Academies of Sciences, Engineering, and Medicine estimates that racial health disparities alone – not including other marginalized groups – could cost health insurers as much as $337 billion between 2009 and 2018.2 “Hospitals and hospitalists have to focus on health disparities in order to address the multitude of chronic medical conditions they treat,” said Dr. Smothers.
For the purposes of measurement, the authors of the RWJF report conclude that “health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” The report attempts to define health equity as a means of specifically addressing it.
“Population health means taking care of the wider population, in terms of health and cost,” said Dr. Fitterman. “But if you’re just looking at the average health of a population you could still be missing pockets of disparity, since there will be pockets that excel and pockets of disparity but the average looks good. If we’re not careful how we measure it, we may leave some groups behind.”
Achieving health equity, the RWJF report says, requires removing the “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Health equity means that everyone must have “a fair and just opportunity to be as healthy as possible.”
It lays out four “key steps” to achieve health equity: 1. Identify important health disparities; 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be healthier; 3. Evaluate and monitor efforts using short- and long-term measures; and 4. Reassess strategies in light of process and outcomes, plan next steps.
Everyone can be a part of the solutions to address health disparities, Dr. Fitterman said. He was not involved in the report. For hospitalists interested in addressing health equity, Dr. Braveman had two recommendations:
• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;
• Put particular effort into helping the most socially disadvantaged patients in their hospitals.
This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.
Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.
Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.
“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”
Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.
Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”
Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.
“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
1. Braveman P, et al.Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.
2.. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.