THE BUZZ THIS WEEK:
The pandemic pushed health disparities1 into the spotlight, revealing and reminding the nation that “health equity2 is still not a reality as COVID-19 has unequally affected many racial and ethnic minority groups, putting them more at risk of getting sick and dying from COVID-19,” per the Centers for Disease Control and Prevention.
In addition to chronic under-funding of public health services and the many social determinants of health that impact community health and outcomes, an important factor preventing health equity is the lack of coordination between healthcare organizations (e.g., hospitals, health systems) and public health entities. This was particularly evident during the pandemic, as the U.S. was caught flat-footed by this lack of coordination, leading to confusion about vaccines (including information, procurement, and distribution), preventive measures such as masking, and treatment options. Dr. Kavita P. Bhavan, Chief Innovation Officer at Parkland Health & Hospital System and Associate Vice Chair of Clinical Innovation and High Value Care at University of Texas Southwestern Medical Center, was quoted in a New England Journal of Medicine Insights Council Survey: “The pandemic has shown collaboration is essential to meet urgent population health needs. You need both [public and private health institutions] to develop, communicate, and execute on response plans.”
There are several factors contributing to the divide between healthcare organizations and public health entities, including:
- Lack of alignment and poor communication.
A recent Commonwealth Fund piece, Bridging Public Health and Health Care to Promote Health Equity, highlighted collaborative work done in New York City. The authors of the piece stated that at the outset of the project, “We learned that the relationship between the health department and hospitals sometimes felt one-sided…with the health department only coming to hospitals when it wanted them to do something…. Many hospital leaders told us they were committed to efforts to advance health equity but didn’t know where to start.”
- Lack of agreement on roles and responsibilities.
A key finding of the recent NEJM Insights Council Survey was a perception among respondents that public and private health organizations can and should do very different and separate things. Per the respondents, private healthcare entities are responsible for delivering care, and public health entities are responsible for the health and health outcomes of a community. While it is true that healthcare providers do deliver the bulk of medical services, both types of entities impact health. Both entities should be focused on improving outcomes. To improve health outcomes, there will have to be aligned, shared activities and a coordinated—not siloed—approach. The authors articulate, “The sticking point is that collaboration would require sharing responsibility for service areas that different organizations don’t believe are in their purview.”
- Mismatched incentives and limited financing.
Currently, the majority of commercial insurance reimbursement models are centered on treating diseases and injuries, not on prevention to keep populations healthy. Though value-based reimbursement models are becoming more prevalent, there aren’t enough monetary incentives to invest in public health services and initiatives as a high priority.
Why It Matters:
To improve the health of vulnerable communities in the U.S., reducing health disparities and improving both healthcare equity and health equity, public and private health and healthcare entities will need to find a way to work more closely and in concert.
The American Hospital Association published a report in 2019, From Common Ground to Shared Action: Lessons from Health Care Systems and Local Public Health Departments Working Together to Advance Community Health. Its recommendations for successful collaboration include:
- Developing a common understanding and shared vision, including agreeing on a target population, confirming shared definitions, and articulating the value each entity will realize, and the collective value created.
- Creating an overall structure and decision-making process, with clear roles and responsibilities, a process for making decisions, and a convening party that can serve as a neutral facilitator throughout the partnership.
- Moving toward shared action, based on the clear objectives, structured approach, shared responsibilities, and a collective call to action.
Monetary support from the participating parties, the government, and grants can help launch public-private initiatives and extend their life cycle. An example of a project addressing health disparities that couldn’t get off the ground due to lack of financing is at Southern University of New York’s University Hospital in Brooklyn. The hospital wanted to partner with a food pantry to open a site within the hospital, providing nutritious food “as a prescription.” As the CEO described in an NEJM Catalyst article, it would take $100,000 to $250,000 to seed the project, which was deemed impossible. “Most private, nonprofit health delivery systems [like ours] do not have a large margin, and therefore we need some of the public funding to help address food insecurity, housing insecurity, and other social determinants of health.”
There are, fortunately, an increasing number of success stories, particularly as healthcare delivery organizations begin prioritizing the reduction in health disparities in their surrounding communities and incorporating that into their overall strategic plans. One such example is a drop-off childcare program that was developed at Parkland Hospital in Dallas, Texas, in partnership with a community organization. The program provided a safe place for children to go while their mothers received medical care services, including preventive care (e.g., breast cancer screening, chemotherapy). As the Parkland Hospital CEO describes in a NEJM Catalyst piece, “We help women who have been neglecting their own health (due to lack of safe childcare as a social determinant of health) feel comfortable seeking care.”
Another example was the subject of the recent Commonwealth Fund report, where collaboration among healthcare organizations and public health entities in New York City resulted in the vaccination of 6.5 million people in less than a year. The program directors emphasized that establishing a new Chief Medical Officer role, responsible for strengthening relationships between the agencies and healthcare organizations, was a key ingredient in the success of the vaccine and other programs. Other factors identified to ensure a successful public-private health endeavor to improve health equity include: increasing engagement between public health departments and providers on a regular basis, prioritizing health inequities, promoting antiracism (e.g., by adjusting clinical decision support algorithms that don’t properly account for minority populations), and building accountability.
The Commonwealth Fund:
Bridging Public Health and Health Care to Promote Health Equity
AHA Institute for Diversity and Health Equity:
Community Partnerships: Strategies to Accelerate Health Equity
Online Event Hosted by the Bipartisan Policy Center and the Nonpartisan Commonwealth Fund Commission on a National Public Health System:
How Do We Create a National Public Health System
1 Health disparities: Preventable differences in health outcomes (e.g., infant mortality), as well as the social determinants of health (e.g., access to nutritious food, affordable housing, and employment opportunities) between populations. These can be measured by differences in incidence, prevalence, mortality, burden of disease, and other adverse health conditions, per the National Institutes of Health.
2 Health equity: The principle that opportunities for optimal health in vulnerable populations can be achieved by eliminating systemic, avoidable, unfair, and unjust barriers. Progress toward achieving health equity can be understood by measuring the reduction in gaps in health disparities between populations.