Measuring Health Equity
How to Improve Accountability
I’m not going to lie. The past few weeks have been a whirlwind of soul-searching and concern over what’s been happening in America. I’ve had tough conversations in the office over what the hospital I work at can do to address racial inequities and systemic racism, as well as efforts to be more ‘anti-racist.’ There’s no easy solutions but I’m glad the conversation has been happening even though the unnecessary death of George Floyd seems like a steep price to pay for it.
Speaking about it has been little help and I highly recommend buying books from your local black-owned businesses to learn more. A few of the ones I’ve read include:
· Te-Nahisi Coate’s Between the World and Me
· Ibram Kendi’s How to Be Anti-Racist
One topic that may be appropriate is how do we better measure inequality and hold institutions such as hospitals accountable for address those disparities?
Disparities Exist and a Major Reason why the US is Ranked Last in OECD
There’s been already enough research on the health outcome disparities of vulnerable populations, that if people’s minds haven’t been changed, its unlikely that additional studies will change things. That or they’re willingly hiding from the fact that health inequities are here in the US.
Aaron Carroll’s listed a few including the fact that:
Black women’s maternal mortality is 3 times that of white women.
Black patients in the US are less likely to receive proper care for diabetes, kidney disease, and various cancers even though they have higher rates of almost every disease.
Addressing these disparities would also do so much to address the fact that American health outcomes are some of the worst among OECD nations.
Since 2000, the Agency for Healthcare Research and Quality has been tracking healthcare disparities, following a congressional mandate to track how the country is doing. .
In 2018, BIPOC (black, indigenous, and people of color) received worse care than White people for about 40% of measures. Nikhil Krishnan shows some of these in his newsletter.
Screenshot from Nikhil’s Out of Pocket Newsletter
Unfortunately, many of the data sources come from the Medical Expenditures Panel Survey, a survey that goes to assess how Americans are accessing and receiving care. These don’t necessarily identify individual hospitals. So how should we hold our healthcare institutions accountable?
A Roadmap to Health Equity Measures
In 2017, the National Quality Forum issued a roadmap to try and help provide some framework.
The development and use of health equity performance measures is what I’ll focus on here.
What defines health equity? According to the NQF, there’s a few including the below listed domains.
A number of these would be difficult measures to track, or worse-yet would be structural or process measures that tick the box for completion. While these are important, they may just end up being assigned for compliance training with little potential impact. I would personally put more merit on outcome measures.
What’s up with compliance stock images thinking they’re in Minority Report?
A few examples of this could include accessibility measures stratified by race or socio-economic status, such as the proportion of patients able to receive ‘same day appointments’ or tracking ‘time to next appointment.’ Doing so would create accountability from some hospitals that have specialized clinics for Medicaid or un-insured patients that typically have weeks to months long waits, while on-demand or same day visits are given to those with commercial insurance in the typical doctor’s office. This is as close to tiered segregation of access as we can get.
Hospitals Already Get Disparities Reports
Another example of equitable high quality care would include stratifying outcome measures by patient socio-economic status and making them publicly available, via resources such as Hospital Compare or data.medicare.gov. These would be disparities-sensitive measures.
One current example that hospital’s already receive on an annual basis from CMS is a confidential disparities report that tracks readmission measures stratified by dual-eligibility status. Patients with Medicare can be dual-eligible, meaning they also qualify for Medicaid. Unfortunately this is also a population that is disproportionately BIPOC.
Readmissions are a commonly used quality metric used to track unplanned visits back to the hospital. While no readmissions isn’t exactly the goal, tracking readmissions overall is important to the US Healthcare System. Hospitals generally have about 3% of their Medicare revenue tied to performance in these measures for specific conditions such as a joint replacement or cardiac care. Typically hospitals are compared against similar hospitals by how many dual-elible patients they see, a modification that was made after researchers discovered that many safety-net hospitals were being punished by the program.
A hospital gets a report similar to the one pictured here. Hospitals get two tabs to identify how they perform on disparities. A within-hospital report that looks at the differences in its own outcomes, the Rate Difference. In this sample hospital, the hospital’s dual eligible population with pneumonia has a rate difference of 1.03%, meaning that dual eligible are MORE likely to get readmitted after controlling for co-morbidities and age.
The across hospital report looks at the how the hospital performs on disparities compared to the typical hospital in the State and in the Nation. In this case, the hospital’s risk-adjusted readmission rate for dual eligibles with pneumonia is about 20.93% complications putting I smack in the middle of performance in the state (17.2%-23.1%). It unadjusted readmission rate though is much worse at 28.18% vs 20.30% for the state and 18.81% for the nation.
Disparity Reports Should be Public
Having these publicly disclosed, rather than a confidential report, could be a useful policy mechanism for ensuring better accountability. Boards of Trustees would want to know more about this and potentially hold senior leadership to account for reducing disparities. Quality improvement resources may be expanded in addressing inequalities and the need for better structural measures may have more bite if there’s specific consequences, such as worse outcomes. Additionally, public disclosure would allow ratings and rankings groups like US News to build these measures into health equity rankings.
Of course, these measures would require some refinement. Social risk factors have still yet to be collected, and CMS is barred from including external sources such as those collected by CDC or AHRQ in their measure methodologies.
Congress should address that or give HHS the authority to use create higher fidelity measures of social risk than just dual-eligibility status. But I’m hoping that these conversations help to create some level of change in our society.
Thanks and as always, if you have any comments or topic that you’d want covered, send me a message: kevin.wang.314@gmail.com