Outcome Disparities vs. Outcome Inequities

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“One’s zip code should not determine one’s health destiny – but in America, it does”

-Robert Ross, CEO California Endowment

Health equity is the focus of much attention recently, with NCQA and DHCS looking for ways to measure and remediate inequities. A major limitation to analysis of health equity in the Medi-Cal population, is that the data available on race, ethnicity, language and gender is self-identified at the time of Medi-Cal application based on limited standardized categories offered by the state. While some providers gather more detailed demographic data, such as gender identity, sexual orientation, or more nuanced ethnicity information, it is not captured in a standardized way and not reported to the health plan or the state, so no analysis based on this more detailed demographic information is possible outside of the provider-level databases. A high priority for making health equity analysis less blunt will be to standardize more detailed race/ethnicity/gender etc. data collected from beneficiaries at the time of application.

Partnership HealthPlan of California (PHC) is able to use the basic member-level ethnicity data we have to evaluate certain clinical data elements that are collected more systematically, as part of HEDIS administrative measures (such as breast cancer screening) or hybrid measures collected as part of the PCP QIP (such as blood pressure control). Outcome data, like maternal mortality or neonatal mortality, is not coded in a way that we can generate accurate rates within our health plan data (county level and state level mortality data is available from CDPH).

There are two patterns that we find with this approach, illustrated with the following examples:

  • Hypertension control: Note the declining control overall in 2020, due to the COVID pandemic. Additionally, note less control of blood pressure in the Black and male populations. This chart is based on QIP data, the denominator being much larger than for HEDIS data, where only a small sample of the overall population is evaluated. Consequently, while we are not able to find statistically significant disparities from HEDIS data, we are able to see statistical differences in the QIP dataset. Diabetes control exhibits a similar pattern.

  • Childhood Immunization: 10 vaccine series completed by age 2. White and Black children have similarly low vaccination levels, compared to the Asian/Pacific Islander and Hispanic children. Many other clinical measures have a similar pattern, with the health status of white members below that of other ethnic groups.

As this illustrates, not all health disparities are a reflection of inequities. If a socially favored demographic (such as white males) has a worse health status, this disparity would not be considered a reflection of systematic bias or unequal privileges. Such ethnic disparities (in the setting where all groups have Medi-Cal, and so all the comparison groups have low income) may be associated with other factors which could be considered inequities. Examples include, living in a rural area with less access to medical care or having a higher exposure to factors that increase health risk, such as housing instability or substance use.

These examples illustrate the challenges DHCS and NCQA will have as they try to define standardized equity measures that measure performance of health plans. Nonetheless, analyzing the data we have to look for disparities is well worth the effort, to allow a thoughtful contemplation of associations and potential causal factors that we may be able to address.

Remembering the Founder of Community Health Centers

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The last time I looked in my textbook,
the specific therapy for malnutrition is food.”

-Dr. Jack Geiger

In December, 2020, Dr. H. Jack Geiger, founder of the first Community Health Centers in the United States, died on Monday at his home in Brooklyn at age 95.

In the 1960s, Dr. Geiger was a co-founder, with Dr. Count Gibson, of Community Health Centers in South Boston and in Mound Bayou, in the Mississippi Delta. They provided desperately needed health care but also food, sanitation, education, jobs, and social services — what Dr. Geiger called “a road out” of poverty. The centers inspired a national network of clinics that now number more than 1,300 and serve about 28 million low-income patients at more than 9,000 sites.

Dr. Geiger was a leading proponent of “social medicine,” the idea that doctors should use their expertise and moral authority not just to treat illness, but also to change the conditions that made people sick in the first place: poverty, hunger, discrimination, joblessness, and lack of education.

During his last year of medical school, he traveled to South Africa and worked with two physicians who were setting up a health center in an impoverished, disease-ridden region of the country called Pholela, which was then a Zulu reserve. A key to the center’s success was that local people — its own patients — worked there and helped run it.

For five months Dr. Geiger took care of patients, visiting thatch huts and cattle kraals, meeting traditional healers and seeing the huge improvements — pit latrines, vegetable gardens, children’s feeding programs — that the health center had brought to the region.

In the summer of 1964, he traveled to Mississippi to help care for the civil rights workers who were pouring into the Deep South to campaign for voting rights.

In Mississippi, he saw conditions much like those in South Africa: families living in shacks without clean drinking water, toilets or sewers; sky-high rates of malnutrition, illness, infant death and illiteracy; few or no opportunities for residents to better themselves and escape. He realized that he did not have to travel to Africa to find people in trouble.

Under President Lyndon B. Johnson, the war on poverty had begun and the Office of Economic Opportunity had been created to pay for projects to help the poor. Sponsored by Tufts University, and armed with grants from the opportunity office, Dr. Geiger, Dr. Gibson, Dr. John Hatch and others set up a health center in Mound Bayou, Miss., a poor, Black small town where most people were former cotton sharecroppers whose way of life had been wiped out by mechanization.

The clinic, which opened in 1967, treated the sick, but also used its grant money to dig wells and privies and set up a library, farm cooperative, office of education, high-school equivalency program and other social services.

The clinic “prescribed” food for families with malnourished children — to be purchased from Black-owned groceries — and the bills were paid out of the center’s pharmacy budget.

The governor complained, and a federal official was sent to Mound Bayou to scold Dr. Geiger for misusing pharmacy funds, which, the official said, were meant to cover drugs to treat disease.

“Yeah,” Dr. Geiger replied, “well, the last time I looked in my medical textbooks, they said the specific therapy for malnutrition was food.”

The official, he said, “shut up and went back to Washington.”

(Adapted from Dr. Geiger’s full Obituary in New York Times)

Patient-Centeredness: In the Eye of the Beholder

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“We are guests in our patients’ lives.”

-Don Berwick, MD

April 26-30, 2021 is National Patient Experience Week, a time for health care organizations to celebrate and reflect upon their efforts to improve the way their consumers perceive the care they receive, a time for health care organizations to proclaim that they are “Patient-Centered.”

What does it mean to be patient-centered? The answer depends on who you ask.

The root of the term “patient-centered” goes back to the 1940s with a school of psychological thought that promoted counseling that was centered on the needs of the client: client-centered counseling. In the 1950s and 1960s, Hungarian-British psychologists Michael Balint, Enid Balint, and Paul Ornstein brought a basic psychodynamic approach to primary care clinicians –the “Balint Group” approach now used in primary care medical education around the world. The Balints coined the term patient-centered medicine, which “should include everything the doctor knows and understands about his patient . . . understood as a unique human being,” as distinct from illness-oriented medicine that focuses more narrowly on diagnosis and treatment of localizable pathology.

In 2001, the Institute of Medicine identified being “Patient-Centered” as one of the six aims of health care quality (the others being safe, effective, timely, efficient, and equitable). They defined Patient-Centered as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring their values help guide all clinical-decisions. This idea of customizing the care to the patient seems consistent with the Balints’ ideas.

Starting in 2007, some larger institutions have appropriated the term patient-centered to have different definitions.

In 2007, all the American organizations representing primary care clinicians (AAFP, AOA, ACP, and AAP) combined the concept of a primary care Medical Home (the 1967 AAP idea of a PCP who coordinates the care provided by specialists), with the idea of patient-centeredness to create the Joint Principles of the Patient-Centered Medical Home. While the goal of this structure is to serve the needs of the patient, this initial conceptualization focused on putting the primary care physician at the center of this care—more of a primary care physician-centered medical home.

Sensing an opportunity, in 2008 the major accreditation agencies (NCQA, URAC, Joint Commission, and AAAHC) launched Patient-Centered Medical Home (PCMH) accreditation and recognition programs. Their focus is on elements of operational and quality infrastructure thought to be good for patients and their outcomes. Moving beyond a narrow physician-centered focus, meeting these elements helps move primary care organizations in the direction of higher quality care, using a compliance with standards approach.

In the meantime, organizations and scholars that were focused on primary care moved in two different directions.

The first of these focuses on relationships between the patient and their clinician who is able to communicate with empathy. This emphasis on relationships is epitomized by the Nuka Model of Care at the Southcentral Foundation in Anchorage, the only health center in the U.S. to win the Baldrige National Quality Award. Health care in the Nuka model is relationship-based and customer-owned. Nuka focuses on understanding each customer-owner’s unique story, values and influencers in an effort to engage them in their care and support long-term behavior change. Note the additional element of community empowerment included in this approach.

The second direction was a focus on more actively seeking input of patients on how to improve the provision of health care, called Patient and Family Centered Care (PFCC). The four fundamental principles of PFCC are treating patients and families with respect and dignity, sharing information, encouraging their participation in care and decision making, and fostering collaboration in care delivery and program design, implementation, and evaluation. The new element here is the idea of moving beyond gathering survey feedback from patients, to partnering with patients to identify service problems and co-design the solutions. “Nothing about us, without us” is their catchphrase.

Both the Nuka model and the PFCC move beyond the individual clinician-patient interaction to look at what the organizations that hire these clinicians must do to be patient-centered, in ways that are challenging for standards organizations like NCQA to fully capture.

Jumping up another level above the organizations that provide care, how can health plans like PHC (as well as suppliers and state regulators like DHCS) promote patient-centered care?

  1. Make patient-centeredness a guiding principle—a frame-of-mind—that guides decisions and prioritization.
  2. Ensure consumers of health care have a voice. This includes a process that uses grievances to drive improvement, including consumers in governance and policy-making, and ideally with some joint design activities.
  3. Support providers, especially your primary care organizations, with financial incentives, comparative data, and sharing of best practices around optimizing the patient experience of care.

Becoming truly patient centered, meeting all the different definitions of this term, requires sustained attention from all of us. Thanks for taking a moment on National Health Experience Week to reflect on what you can do meet this ideal.