Health equity exists when everyone has a fair opportunity to be healthy. Fair opportunity can mean different things and manifests in different ways depending on geography, population composition, comorbidities, prevalence of social determinants of health (SDoH), and more. The topic is all the rage at healthcare conferences or in the news. But what does true person-centered, equitable care look like? Do we, as a community of healthcare professionals, even understand the basic demographics of the populations we are tasked to serve and if not, what should we be doing to facilitate universal access to all?
Fortunately, the Centers for Medicare and Medicaid Services (CMS) has grounded us by providing a clear deﬁnition of what it means to improve health disparities. In 2021, CMS laid out its strategic direction for the next decade. At the core of their initiatives is their vision: “A health care system that achieves equitable outcomes through high quality, affordable, person-centered care.” To do this, their strategy focuses on driving accountable care, advancing health equity, supporting innovation that closes care gaps, improving access by addressing affordability, and partnering with others to achieve system transformation. It’s an audacious and important goal that has ﬁnally been clearly deﬁned for our whole industry.
But, big audacious goals are often complex and their execution is non-linier. What tangible actions can we make in our industry to harness the best of our people, process and technology to create real progress towards these goals?
Getting to know your population
We’ve seen ﬁrst-hand how a data-informed approach can bridge the health equity gap. It may seem simple but understanding the unique drivers of your population groups is critical to tailoring impactful care — there is no one size ﬁts all. For example, a 4.5 star health plan that we work with identiﬁed that the impact on primary measures were predominantly driven by non-compliance attributed to their Latinx and Black members. Historically, the approach of reaching out to these populations to drive treatment compliance was no different than the approach the health plan used to improve these outcomes among their White or Asian populations. Research has shined a light on the health equity gap between Latinx, Black and white American populations. It became incredibly important for healths plan to rethink their outreach approach for their Black and Latinx members to drive compliance — ultimately saving the plan vital funding and promoting better health outcomes for the individual.
Enter a data-informed approach: 5 steps to address health disparities
Changing the outreach approach requires a data-driven focus. To do this, there are 5 key steps:
1. Deﬁne what health inequities look like in your population
2. Identify SMART goals to address 1-3 of these inequities
3. Identify data sets to identify, address and track impact of your actions on health equity
4. Apply data science framework to inform culturally appropriate care delivery
5. Operationalize learnings by enhancing people, process and technology
First, you must identify the inequities: are these disparities impacting cost and revenue, or are they patient-focused? Do they cause worse health outcomes, limit access to care, or impact the quality of care for these populations? The health plan must identify which priority was most important.
Next, the plan must identify SMART (Speciﬁc, Measurable, Attainable, Relevant and Time-bound) goals based on what health inequity looks like in that organization’s population. This can be radically different by population. The SMART goals deﬁne the meaningful, incremental targets that can bring the organization incrementally closer to their health equity objectives. The goal here is incremental progress, since the CMS has stated this is the priority for the next 10 years.
Once the problem area is identiﬁed and SMART goals are set, they need to determine which data sources would allow them to identify and track the problem. Without any measurement, they wouldn’t know if they are tracking toward the deﬁned goals. Additionally, publicly available
third-party data sources can be used to enhance the existing health plan data set.
Through augmented intelligence using the data, the health plan is able to identify the characteristics that are endemic to their targeted population groups — Black and Latinx members. By using third-party consumer data and social determinants of health data, they create ‘member personas’ that tell a bigger picture story about who the people in this demographic are. The member personas get at the motivations behind their members: what motivates them, their family structure, language of origin — all data that can be overlooked in the clinical setting. Based on what the data tells them, they can better understand how their Latinx members differ from the rest of their member population.
Finally, the data and personas are put into action. The information in them is used to ask the right questions that enhance the people, process and technology to meet the goals identiﬁed by the health plan. For example:
● People: Do we have bilingual resources who can perform culturally and linguistically appropriate outreach to the Latinx population?
● Process: Do we have the right processes in place to identify, stratify, reach and transform the behaviors leading to adverse outcomes for these members?
● Technology: How can we leverage technology to make some of the above process steps easier for the people who are trying to make an impact in the lives of the people we serve?
Why this matters
Health inequities are personal and unique to each health plan and their member population. It’s imperative that people are able to access appropriate care in a language they understand, so that they can make the best decisions for themselves and their families. While there’s no silver bullet to solve the issue of health equity, there are simple ways to use data to identify where there is opportunity for your plan to improve disparities in health and health outcomes. Enhancements in people, process and technology tools are the small incremental steps needed to get us to our larger goal of health equity for all.
Within the industry, we are challenged to ask ourselves questions about how well we know the population we serve and if we are truly offering culturally appropriate care. We are all at the start of the journey to truly understand how health equity impacts our networks. Please take ﬁve minutes to respond to our anonymous survey to share your views, understanding and priorities for health equity.