Achieving health equity is a major social challenge facing our nation. In an ideal world, the best care would be given to all patients—regardless of socioeconomic status, race, gender, or other identifying traits. In reality, however, health care disparities still exist.
Health inequities are the result of many factors, including income, education, geographic location, and other demographic characteristics. Health care equity, on the other hand, focuses on the care that patients receive as they traverse the health care system, such as outpatient clinics, inpatient treatments, medication prescription, and adherence to the prescribed treatment.
Although health care equity represents only a relatively small part of health care delivery, it is still a major challenge and, more importantly, one that is more likely to be influenced by health care providers. Health care equity can contribute significantly to improving outcomes of medical and surgical conditions, as well as our patients’ experience of care.
I was recently reminded of these challenges when I read an article in the April 2018 issue of The Joint Commission Journal on Quality and Patient Safety.* The study analyzes the effect of hospital peer groups in adjusting for socioeconomic status (SES)—or “social risk”—in the Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP). The use of hospital peer groups affects the number and distribution of hospitals penalized for higher readmission rates. This issue is timely, as CMS plans to adopt hospital peer groups for its fiscal year (FY) 2019 rate adjustments. The study findings are unsettling for both hospitals and surgeons.
To provide some perspective, here’s some background information on this issue. In 2016, the 21st Century Cures Act directed CMS to develop ways to prevent hospitals that care for more patients with low SES from being inappropriately penalized because of higher readmission rates.* Patients who are poorer or less educated may have fewer resources to help them avoid readmission, which makes it difficult to compare hospitals that disproportionately care for patients with low SES to hospitals that care for patients with higher SES. Grouping hospitals into peer groups with similar patient populations is a proposed solution.
For the study—“Will hospital peer grouping by patient socioeconomic status fix the Medicare Hospital Readmission Reduction Program or create new problems?”—Richard L. Fuller, MS, and colleagues used CMS analysis files for the FY 2017 HRRP final rule and disproportionate share hospital adjustments to assign hospitals to peer groups.* Key findings in the study include the following:
- Use of peer groups introduces differing performance standards for hospitals, which may be affected by factors such as volume or lower-quality care being routinely delivered by hospitals with larger shares of low-SES patients.
- For surgical cases, hospitals with fewer patients had higher readmission rates.
- For medical cases, hospitals with fewer patients had fewer readmissions.
The authors observed significant volume-outcome effects for medical conditions, which runs counter to the hypothesis that low-volume hospitals will be resource-constrained when trying to manage hospital readmissions. The authors conclude that further research is required to better understand the volume-outcome relationship observed within medical conditions in the context of the HRRP.
These results are concerning. Just last year, at UW Medicine, Seattle, WA, colleagues and I created a Healthcare Equity Blueprint with the vision of making our health care system a model that other health care institutions could use to improve health equity.†
While the creators of the blueprint grant that health care equity is neither a short-term project nor a problem with simple fixes, we assert the blueprint and its goals are the next steps in a long journey. The objectives in the blueprint are as follows:†
- Increase diversity, increase cultural humility, and reduce implicit bias in the health care workforce
- Engage the communities UW Medicine serves as partners in assessing and addressing health care equity
- Deploy targeted quality improvement and health care services to meet the needs of marginalized populations
The Fuller article points out a big hurdle to that third objective: Until the playing field is level and hospitals are not penalized for the outcomes of caring for all patients—regardless of SES or other differences—reducing health care disparities will continue to be a challenge.
The Fuller study can be accessed on the Joint Commission Journal on Quality and Patient Safety website.
The Joint Commission has a wealth of resources regarding health care equity, which can be found on its website in the Health Equity web portal. This page includes the following resources:
- Speak Up campaigns on patient advocacy
- An interview on implicit bias with Ana Pujols McKee, MD, executive vice-president and chief medical officer at The Joint Commission
- Monographs, standard frequently asked questions, and health equity case studies
The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.
*Fuller RL, Hughes JS, Goldfield NI, Averill RF. Will hospital peer grouping by patient socioeconomic status fix the Medicare Hospital Readmission Reduction Program or create new problems? Jt Comm J Qual Patient Saf. 2018;44(4):177-185.
†Ramsey PG, Pellegrini CA. UW Medicine healthcare equity blueprint. Available at: http://cedi-web01.s.uw.edu/wp-content/uploads/UW-Medicine-Healthcare-Equity-Blueprint-05-01-17.pdf. Accessed April 30, 2018.