Looking forward on addressing racial inequity in healthcare
Dalton Tong, a longtime healthcare finance leader — and likely the first Black member of the HFMA National Board — shares his story and suggests ways colleagues can improve opportunities within healthcare and across society for Black people and other minorities.
After waves of racial unrest broke across the country in 2020, healthcare organizations and leaders have renewed their focus on the effects of racism and racial disparities. As healthcare leaders look for actions to address those challenges and health inequity issues, Dalton A. Tong, FHFMA, CPA, MBA, 70, shared his experiences and vision of how the sector can help.
Following 50 years serving in various roles in healthcare finance practice and education, Tong sees progress and improvements, as well as the need for new efforts to bolster low-income, minority patients and attract more Black professionals into the field.
Tong’s hard-won insight on the challenges and opportunities for improvement stems from nearly 30 years of working in various healthcare finance and leadership roles in the Baltimore-Washington, D.C., region followed by two decades instructing new generations of students on the intricacies of healthcare finance.
The insight also stems from his roots in Guyana, in South America, where his mother raised him and his three sisters. Growing up without access to running water and substantial meals, Tong worked to advance through education. At 14, he obtained international certification to teach local high school students and only later was able to obtain his own high school diploma at night school, while working during the day.
In 1970, at the age of 20, Tong immigrated to the U.S. to study accounting at the University of Baltimore. Within months of starting college, he took a part-time accounting clerk job at South Baltimore General Hospital.
Three decades later, Tong would serve as the director of the University of Baltimore’s honors accounting program and as a senior professional faculty member of Johns Hopkins University.
“I have come from a faraway place to a point in my life where I can reflect back,” Tong said.
Reflecting in public did not come easily to the modest Tong, but instead followed the prodding of his adult daughters to share his story and insights and — hopefully — to inspire others to follow in his footsteps.
“Why do Black students want to go to engineering school? They see Black astronauts,” Tong said. “Why do they want to go to medical school? Why do they want to become lawyers? They see pictures, they see evidence of the investments and the rewards. Healthcare finance should do the same thing.”
What healthcare finance can look like to minorities
Tong recalls that for his first job in a hospital, his “office” was in a hallway near the bathroom entrance. It was a strange arrangement that only later drew Tong’s reflection.
“I was insensitive to what was happening then,” Tong said. “When I reflect now, I can see some unconscious bias perhaps that may have been at work, or perhaps there was some consciousness about [my] desk location to say, ‘Here’s this young Black guy who is here with us. Let’s put him where he belongs.’”
But Tong continued to pursue his education and professional training, and within 10 years had risen to vice president of finance for the 500-bed teaching hospital.
“I went from the restroom to the boardroom in a few years at that place,” Tong said. “Therein resides the satisfaction, I suppose.”
The hospital also invested in Tong, including funding his participation in a Harvard executive education program.
In 1985, Tong went on to become CFO of Greater Southeast Community Hospital. Six years later he became CFO of Greater Southeast Healthcare System, based in Washington, D.C., its COO in 1992 and its CEO two years after.
“That has probably happened to a lot of people, [but] we don’t talk a lot about it among Black people in healthcare,” said Tong of his career trajectory.
Tong talks about coming to “an intersection of success and loneliness” at one point in his career.
“I had achieved all of this stuff, but there were times where I would go to meetings and, being the only Black person, I was so ostracized and couldn’t chat with people,” Tong said about his time as a mid-level executive. “I may have had a suit and tie [like everyone else] in the room, but I was not even recognized. I had arrived, man, but you’re still very lonely.”
How things have changed
The healthcare sector has changed over time in some important ways. That low point in Tong’s professional outlook was followed by what he describes as “gradual inclusion.” Tong attributes part of that improvement to his involvement with HFMA.
HFMA's then-CEO, Dick Clarke, reached out to Tong in the early 1990s, by which point Tong had served as president of HFMA's Washington, D.C., Chapter, about rising to serve as a chapter liaison representative for Washington, D.C., North Carolina and Virginia.
“Dick took an interest and ensured that I felt I belonged in the organization,” Tong said.
Tong rose to serve on the HFMA National Board for two terms, spanning 1993 to 1995. Although the Association does not have records on the race of Board members, Tong is believed to be the first Black member of the Board. When HFMA created a National Diversity Task Force in the early 1990s, Tong served as chairman for three years.
Continuing racial challenges in healthcare
The societal climate for minorities, including their health status, is a continuing challenge, but there are opportunities for finance leaders to drive improvements.
Tong has long reflected on the rise of racial concerns in U.S. society and sees a variety of ways that the healthcare industry, including finance, can help address those. For instance, Black people are twice as likely to be uninsured as white people, according to a U.S. Census Bureau report. That can pose a significant financial barrier to care.
“We’ve made tremendous progress, but at the same time there is still a void of attention that needs to be addressed,” Tong said. “It’s a malignancy, but it is potentially curable.”
Tong cited the need for metrics with which to measure progress over time. However, sharp disagreement among those who want to address inequities in healthcare remains about those metrics, such as total number of minority and women employees versus numbers in leadership specifically.
In healthcare, racial inequities are starkest in the indigent population, which remains the case despite the Affordable Care Act having ameliorated the situation somewhat, he said.
“People go to bed and the nightmare they have is waking up the next morning to find they have no healthcare insurance,” Tong said. “Availability and access issues will continue to be on the radar screen because they have eluded us. Sustainable access, sustainable availability.”
Another priority for healthcare in efforts to reduce racial disparities is addressing the cost of care, he said.
“We need to find leaders who can imagine ways to bring together the right, unbiased minds devoid of political instincts, but just caring minds who can sit down and begin to imagine what a utopia healthcare system might be like,” Tong said. “It’s very possible, but it’s not going to be easy.”
Tong said healthcare CFOs can better stand up for others by first standing up for themselves.
“They would have to be at least as courageous as others have been in insisting that they have a voice at the table, not just pencil pushing and looking at numbers, and helping leaders to understand the impact of those numbers,” Tong said.
The lesson came from his own experience when he aimed to move beyond his organization’s numbers to find ways to convey their meaning.
Training can allow finance professionals to distinguish between needs and wants, target efficiency, engage in optimality and drive toward good choices.
“The CFO is in the pivotal position. They control the money, and if they are listened to, they can then share their professional discipline to get boards and communities to buy into what, at times, could be a sacrifice,” Tong said. “But ultimately, it would allow a sustainable outcome that would make for a better product.”
Major systemic change likely will mean some form of rationing, Tong said, because there is a scarcity of resources. That scarcity will require CFOs to make choices, and changes may entail less spending on personnel and more spending in technology.
“How much we spend, where we spend money, how we staff and where we staff for optimal results [are all key decision areas],” Tong said.
Technology, such as better diagnostic and therapeutic technologies, may mean fewer people are required to drive outcomes. That can be both a challenge and an opportunity.
“That might be a value-added presence that a CFO might have. If they can imagine a future that is so different, and if they can help plan for the acquisition of the response to that future, it will help sustain their organizations in ways that weren’t heretofore imagined,” Tong said.
Healthcare CFOs also can help address racial disparities in health status by focusing on prevention and wellness in the community. Those were significant priorities when Tong was a leader at Greater Southeast Healthcare System.
“We went into community clinics, we prepared young teenage mothers for interventions before their babies were born because when we didn’t do that, we saw the results: Sick babies in our NICU units costing a lot of money,” Tong said.
Initiatives also included outreach to barber shops, where the health system encouraged Black men to receive blood pressure checks while they were getting haircuts.
The critical challenge of attracting minorities to healthcare finance
Even though there are no active barriers to opportunities for Black people and other minorities in healthcare finance, growing their ranks within the industry segment will require a commitment from organizations to pique the interest of potential recruits.
Initiatives that can help minority recruitment efforts include scholarships, the sharing of anecdotes by finance members from different demographic groups and initiatives to create access.
“If organizations can create ways to make that happen, to make students have an interest in becoming part of the organization, it will go a long way,” Tong said.
Tong has aimed to follow that advice during teaching stints at multiple colleges, where he has urged young Black students to consider careers in healthcare finance.
“I would say, ‘Here is an opportunity waiting for you in healthcare finance. Even though you don’t see a lot of faces that reflect the composition of that industry, feel free to venture into it, and I am here to help you,’” Tong said.
Having more minority members in healthcare finance may result in improved empathy for the situations faced by patients who cannot afford their care.
“Having people at the front line in the hospitals, the business counselors and the debt collectors, etc., showing a little bit of patience might help,” Tong said. “A lot of that might go against the grain of the economic objectives of the organization, the profit imperative. If you can find people who can manage that profit imperative with some dose of empathy here and there without collapsing your organization, it would make for a good outcome.”
Beyond a lack of broad insurance coverage, health inequities are driven by divergences in the availability of healthcare.
“It is one thing to access it. It’s another thing to ensure there are the right capabilities in these institutions,” Tong said, referring to hospitals that serve large low-income minority populations.
He highlighted the need to reverse the increasing technological gap between suburban hospitals and inner-city facilities. That way, no matter where healthcare facilities are located, they would have capabilities like high-quality neonatal intensive care units.
“I’ve worked in urban healthcare in Washington, D.C., and Baltimore, and I can tell you, [for] the poor population, there [was] a difference in the care they got at the time,” Tong said. “There was a difference in care because they have no insurance to command that care.”
That challenge applies beyond the uninsured to patients enrolled in Medicaid.
Medicaid “provides some level of health subsistence, [but] it is not the optimal care that the same person with a bad liver or gall bladder is going to get out in a county somewhere,” Tong said. “I loathe saying that, but it is the reality.”
Tong urged healthcare finance professionals to lead in addressing societal inequities and healthcare disparities.
“We should let people know that [for] this problem we call the healthcare problem, the solutions reside with people who matriculate and come out of the healthcare financial ranks,” Tong said.
Tong said some were not surprised that he became a health system CEO after serving as a CFO because of the insights the finance role provided.
“I had my hands on some buttons, and I knew where the resources resided; I had a discipline that I cultivated about measuring and understanding needs and wants,” Tong said. “HFMA in its programs and education can cultivate a society of solution-makers, who can then be mobilized around the country to make a difference in these situations when we encounter them.”