Community health needs assessments indicate that hospitals increasingly are focusing on health disparities, but few have implemented steps to address the issue.

June 6—The business case for hospitals and insurers to reduce health disparities may not yet be clear, even as more move to undertake such efforts, researchers say.

Healthcare organizations are under increasing stress in a rapidly evolving industry, with multiple regulatory and accreditation standards that are changing and slim operating margins, said Scott Cook, PhD, deputy director of the Solving Disparities Through Payment and Delivery System Reform program at the University of Chicago. So asking such organizations to take on health equity efforts will require some help.

“Even though they want to do this work and even though we know how to do this kind of work, they still struggle,” Cook said. “We need a better business case, we need a better business model to give them the resources, the incentive, and the time they need to do the work.”

The extent of the gap between talking about reducing health disparities and implementing efforts to do so was illustrated to Cook by his examination of a Robert Wood Johnson Foundation (RWJF) solicitation for proposals for alternative payment models with a disparities-reduction component to promote health equity. He found that none of the 40 submitted proposals would have made any payments contingent on successfully reducing disparities. Instead, the models focused on improving health outcomes.

“That’s great and needs to happen, but they weren’t willing to take the step of saying, ‘We’re going to reduce that difference between the majority group and the group that’s doing worse,” Cook said.

Reducing health disparities does not always mean targeting improvements at minority populations. Cook cited recent research from Virginia that found Hispanics had superior outcomes and that non-Hispanics needed targeted help.  

The applicants to RWJF were representative of a larger trend. Payment systems generally do not directly encourage or support the reduction of health disparities, Cook noted.

Among the challenges—even for healthcare organizations that want to emphasize the targeting of disparities—is that the large number of other quality and cost priorities leaves little time for such a focus.

“Hopefully by trying to change how we pay for health care, that will give them the resources and the time to make that happen,” Cook said in an interview.

The long-term business case for such efforts is especially strong in the area of population health, Cook said. Such initiatives could add a disparities component to incentivize analyses that would identify differences in outcomes based on race, for example, and then incentivize closing that gap.

“There’s definitely some talk and some movement around making that happen,” Cook said, referring to awareness-raising efforts by organizations such as the National Quality Forum. Additionally, the Center for Medicare and Medicaid Innovation seems “intrigued” by the concept of disparities reduction but has not yet taken steps toward including it in their pilot payment models.

“In terms of getting very concrete and trying very explicitly through very real-life-based implementation, it’s not happened yet that I know,” Cook said.

The need for such initiatives was demonstrated by previous research that found healthcare delivery accounts for as little as 10 percent of overall health outcomes. Instead, behaviors that affect a much larger share of outcomes are determined by patients’ environments, such as whether communities encourage physical activity and provide access to healthy foods.

“We see an opportunity here that there is a shared interest across [economic] sectors in trying to address those issues,” said Steve Woolf, director of the Center on Society and Health at Virginia Commonwealth University. “And frankly, none of them can achieve transformational changes without cross-sector collaboration.”

Hospital Focus

Not-for-profit hospitals have increased their focus on health disparities in recent years, said Amy Carroll-Scott, an assistant professor at Drexel’s Dornsife School of Public Health.

“That is our feeling, that we’re seeing a bit of a shift” toward greater focus on health inequities and the social inequities that drive them, Carroll-Scott said in an interview.

Her assessment stemmed from studying community health needs assessments (CHNAs), which the Affordable Care Act required not-for-profit hospitals to file to maintain their tax-exempt status. In a recent study by Carroll-Scott and colleagues, all 179 hospital CHNA evaluations of local health needs included at least one implicit health equity term (such as disparities), and 65 percent included explicit health equity terms (such as equity). But only 9 percent of implementation strategies included an explicit activity to promote health equity.

Such findings indicate that a lot of hospitals still “see this requirement as a ‘Check the box, we did it’ obligation,” Carroll-Scott said.

Carroll-Scott and her colleagues concluded that hospitals need incentives and additional capacity to invest in the underlying social and economic conditions that cause health inequities.

Given the small share of health outcomes determined by health care, Carroll-Scott said hospitals that are responsible for the overall health of given populations have an imperative to find ways to influence health beyond delivering the best possible care.

Possible Payoff

Hospital spending in the areas of social determinants of health includes funding of job-placement and job-training programs. Such efforts have a huge potential payoff, according to other recent research.

A study that simulated improvements in three social determinants—education, employment, and income—found that increasing employment was significantly correlated with improvements in mental health outcomes.

“So you could think that they could have a return on investment, but it’s complicated,” Carroll-Scott said.

One way to help hospitals would be through policies that encourage capacity-building partnerships to ensure hospitals are not alone in targeting social determinants of health, Carroll-Scott said.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, June 06, 2017