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AHLA Convener on Racial Disparities in Health Care, Part 2: Institutional Decision Making

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AHLA hosted a one-day virtual convener on April 12, 2021 where participants discussed all aspects of health disparities and equity in health care, social determinants of health, the impact of law on these issues, and what can be done to address these issues now and in the future. 

In Part 2, Myra Selby, Partner, Ice Miller, moderates this discussion about how institutional decision-making perpetuates racism, discrimination, bias, and lack of equity, and how organizations can adopt anti-racist policies and procedures.

Watch the full conversation here. Access full video and audio recordings of the proceedings at americanhealthlaw.org/racialdisparitiesinhealthcare.  

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Speaker 1:

On April 12th, 2021, a H L A, hosted a one day virtual convenor, where a panel of distinguished participants discussed important aspects of racial disparities in equity, in healthcare, social determinants of health, the impact of law on these issues, and what can be done to address these critical issues. This five part series presents each recorded session of the convener, full video and audio of the proceedings are available@americanhealthlaw.org slash racial disparities in healthcare.

Speaker 2:

Thank you, Vaughn. And what an exciting start, uh, to our, um, entire, uh, convener. Uh, today I'm gonna talk about, um, an area that is a contrast, I think, to what we've heard. What we've heard from our first panelists is about constructing, about building. Um, and now we'd like to turn to the question, how do institutional decisions perpetuate racism, perpetuate discrimination, de perpetuate bias, and a lack of equity? And for this, uh, part of our discussion today, we're gonna have a sort of wide open panel. So I invite anyone who is, uh, with us today to chime in on, on this particular, um, area of discussion. Um, I'd like to first maybe invite, um, Raia to talk a little bit about, um, institutional decisions from a, a workforce diversity perspective.

Speaker 3:

Thank you. Uh, and I'm excited to talk about this. So I think one of the things that we don't, uh, consider as much as the ways that hospitals and healthcare facilities are microcosms of the greater community. And so when we think about equity, um, in terms of those institutions, we need to think about how they treat all of the people who work with them. Um, particularly thinking about some of the low wage workers and some of the independent contractors that work for them, and to ensure that they do not lack access to healthcare, health insurance and can be healthy. Uh, when I was in Cleveland, we saw a few of the healthcare institutions really committed to this, um, including Metro Health, where they decided to, uh, pay for the health insurance of all their workers, um, especially the lower wage workers to ensure, um, that they also raise the minimum wage to$15, especially for, again, their low wage workers. And this is so key because we don't often take into consideration how these, uh, members are part of the community that they, uh, oftentimes try to seek to get healthcare there. Um, and that is a greater example to the larger community, how you treat, uh, your lesser workers. And I just highlight that it's not just right, the people who clean who serve food, but we often have to think about some of the traveling nurses who are a part of that if these institutions have nursing homes and provide homeland community-based care that all of these people work within the healthcare, uh, structure and system, but often are at poverty level, can afford insurance. And so that is another, uh, way to think about equity, that if we do not provide for these workers, then we are just perpetuating discrimination and unequal access to healthcare.

Speaker 2:

Great. Thank you for leading us off. Um, um, Raia. And what about inserting equity into decision making across the continuum of care? Um, I, I pick up on a little bit of what you said at the end there about, for example, in long-term care, um, and, and a lot of, of, um, um, facilities where much of the workforce is, uh, working at the very lowest end of the wage scale. And what we've seen during this period of C O V D is that's the vector that's been most exposed, most exposed to the disease, most exposed to, um, the, the, the vagaries of employment and unemployment and least protected. Um, and so is that part of what you talk about when you say we, we really have to look at who, um, is included in the community and it is the people who work, uh, in the healthcare, um, arena broadly.

Speaker 3:

Yes. Uh, and so, um, I definitely throw it out to e everybody else too. But, uh, I was able to write a paper, uh, around this, around nursing home care, um, particularly the disparities that we saw during covid in terms of deaths, um, particularly in predominantly black and Latino nursing homes, but then also connecting that with the workers, right? The fact that many of the workers were unprotected, didn't have PPEs, didn't have paid sick leave, weren't covered under many of the economic relief bills, uh, because they were exempted out because there was a worry. We wouldn't have enough people working in nursing homes and providing community-based care. And so we do not really hone in on this problem, and we don't keep track of the workers who have been impacted by covid 19 in nursing homes and home and community-based care, um, even as we track the numbers of deaths of residents who were impacted. And so really ensuring that institutional decisions to move us towards equity include all the people within the healthcare system, including, uh, the workers, particularly the vulnerable who, who provide care to the most vulnerable in nursing homes and home-based care.

Speaker 2:

So how do we go about doing that? How do we go about inserting equity into decision making across the continuum of care? We've heard in the first segment that a lot of this work has to start with leaders start at the top, um, from Andres and others. Um, and, and so if that is a given, um, how in, in, in the, you know, the institutional, um, aspect of the healthcare system, uh, do we begin to move that needle? And I would invite anyone to chime in.

Speaker 4:

Yeah. Myra, I'll jump in here. Um, sure, certainly since you, um, mentioned Mihir in terms of one of the comments that I made earlier, uh, you know, as I referenced in the first session, um, you know, we have been, um, this has been a 10 year in the making, uh, uh, certainly journey for us. And we started, of course with a diversity and inclusion, uh, journey that became really that foundation for us. And about five and a half years ago when I arrived here is when we build the health equity, especially when we signed the 1 2 3 for equity pledge that actually has four key mandates, four key goals. One of them was actually, um, around, um, you know, collecting the data, right? The rail data that we call it race, ethnicity and language preference. But we didn't sub there. We actually ended up, you know, collecting other data in terms of soji, sexual orientation, gender identity, also military veteran, uh, background of our patients disability as well. Cuz we understood that it was important, right? For us to really look at all the different dimensions of diversity. And so part of our journey has been, um, looking at being very intentional and strategic, right? And looking through that equity first lens. And so part of what I will say here is that where eSight matters, right? Typically our function of E D i equity versus inclusion tends to only recite a report into hr. And the issue with that is that then you become just a human capitalist by nature of that. Um, what I love about freighter is that actually I reside under the E V P C O of our system. So that allows me to sit around the same table with all the other chief officers and really have really great discussions around the work that we are driving collectively right? As an organization. And then really helping and advising and also mentoring all of my leaders so they can start developing their own e d i right lens and or exercise those muscles so then they understand what's within my purview, how do I bake it in, and then how do we drive that, right? Ultimately it's really has to be woven into the fabric of the organization to all the goals that you're driving and then having very clear metrics. Uh, because if not, if you don't do that, then you won't know whether you're achieving the collective impact. And then ultimately then having, as I mentioned, the last piece for us was about a year and a half ago when we decided to go one step further and then tie compensation into all of our goals. Cuz certainly then this also now hits the pocket bug, right, of everyone in the organization and it creates one more level of accountability for all of our leaders. And so that's the way in which we have been able to, uh, weave it into all of our goals. It's actually part of the overall strategy. So there's no, uh, goal within freighter in the medical college that we have not thought through from an e D I perspective. And we have, uh, begged those elements into those goals. And I think that that becomes paramount if you are certainly, again, committed and you're gonna be driving, um, a true equity diverse inclusion and anti-racism strategy.

Speaker 2:

Um, I'm wondering if we can hear from, um, Harold, um, because I saw your comment in the chat and you've got an interesting perspective also to bring in here

Speaker 5:

<laugh>. Um, yeah, I put a, a link in the chat to, uh, an oped my colleague Amva and I wrote in the Times last year where we looked at payment models. So a as we just heard, there's a lot of potential for a hospital systems within their own, uh, cultures to turn things around. But in many ways they also need to respond to the incentive structures that are established around them. And so in many ways, we see good initiatives that try to reward not just peace rate doing a lot of things, but try to reward value and focus on outcomes. But some of these pro uh, proposals can have unintended consequence in that you don't want to have a payment model that rewards you if you have low readmissions or achieve particularly good outcomes. If that then leads to shunning, uh, more complicated patients who, because of the consequences of structural racism, are more likely to be minorities. And yet we've seen that and the, the link that I've, uh, sent you documents, uh, several studies that illustrates is we've seen that happening. So what we suggested in our pieces, one, that we need to have a good sense of what's actually going on because we don't, this is another one of those aspects where we don't deal with structural race racism where somebody just says, well, you're black, I don't like you. That's a sort of dumb version of, of racism that I think is not very interesting as appalling as it is. But we are dealing here with another form of, uh, uh, basically unintended consequences, if you want to call it that, to not offend anybody. But I think in many ways, uh, it, it raises all the same issues that we need to understand what is going on. We need a actual review of systematic review of those kinds of policies and systems that enable us to have warning flags zero up if it turns out that some of these models do have the consequences that more disadvantaged populations are shortchanged in the pursuit of efficient delivery of healthcare. So I think that's something where, whether legally you call it disparate impact monitoring or process evaluation and more health service research oriented terms, but something where we wanna make sure that a major initiative that is underway, that directs payments in ways that rewards, uh, good outcomes, doesn't lead to more disadvantaged communities and by implication, uh, more, uh, uh, minority populations to be, uh, short change in the process. So I think that's, uh, another key part we, we, we really need to pay attention to.

Speaker 2:

Thank you, Harold. And I'm, I'm gonna give, um, um, uh, a brief introduction because you, you have not been previously introduced, uh, uh, to our, um, to our panelists. So, um, Harold Schmidt is, uh, the, an assistant professor, uh, at the Department of Medical Ethics and Health Policy Research Associate Center for Health Incentives and Behavioral Economics, uh, at the Pearlman School of Medicine, university of Pennsylvania, Dr. Smith's research interests are centered around improving opportunity and reducing disadvantage for marginalized populations in health promotion and healthcare priority setting. So

Speaker 5:

That's all correct. And, and I'm really glad to be here. Cause one of the things I really regretted not having studied is law. So I'm very honored to be with many of you since I've learned a lot from reading your work. But here I get to talk to the real lawyers. So I'm very pleased about that.

Speaker 2:

Yeah, and I would invite Vaughn, uh, to, to jump in here because she's added some comments in the, in the, uh, chat as well. Vaughn.

Speaker 6:

Uh, thanks m Mara. I, you know, I, for me, it's just about us asking different kinds of questions. You know, we've been operating in a very specific paradigm in this industry for so long that I think we've forgotten how to imagine and think creatively. And so we need to bring that back. What is the equity impact should be a part of that conversation. But we have to intentionally insert that question. It's not currently built into the way we think about our problem solving, right? We have to, and we have to intentionally insert the idea of, if, if our value that we are adding is that we are eliminating disparities and that we are reducing inequity in our system, then we have to build those kinds of questions and conversations into our process for how we plan. But right now, there's not, not really a lot of mechanism for doing that, because, as Harold said, the pavement models haven't caught up to that yet. And, you know, a lot of the strategic that's taught in health policy school and in business school doesn't focus on any of that. So I think we just have to start asking some different kinds of questions and, and be willing to go there.

Speaker 2:

Yeah. And doesn't that require, won't, won't that require a, a c change in terms of the, um, because a a, as we all know, the payment system, right, right now is designed around a lot of different incentives, all labeled, uh, paying for outcomes, uh, that, that our, uh, payment system right now has moved from paying for procedures to pay, paying for what is done to a patient, for example, to, uh, now paying for outcomes. And so how do we, how does, how does equity and health justice, um, play into that, if at all? Or it does it require, uh, uh, an entire, um, system redesign?

Speaker 6:

I mean, for me, I think we have to talk about what we mean by outcomes. I think right now we have a very narrow definition of outcome in terms of what is the result of the procedure that, so instead of paying for the procedure, we pay for the result of the procedure, but the outcome in terms of someone's whole health is much broader than the outcome of an individual procedure. So I think that, you know, from a policy perspective, we get to have a very different conversation about what do we mean by outcomes? What are we even measuring? You know? And I think that's, that's, again, it's about thinking a little bit more broadly instead of reacting to the way the current system doesn't work. Let's imagine something a little bit different. Imagine something new, not throwing everything away, but let's, let's get out of the paradigm of, well, we put bandaids on this, and so well, instead of paying for the bandaid, let's pay for the scab that forms six weeks after the bandaid. Okay, well, you know, we're still focused on the bandaid, you know, let's talk about what it means for them to not get cut in the first place. Let,

Speaker 5:

No, just second that. I, I would just second that. I think you, as was mentioned in the chat too, right? We want to talk about what value here is. So I don't think the problem is a conceptual one with focusing on outcomes as, as you've just said, the question is, well, what are the outcomes if it's reductions in access to healthcare across groups defined by meaningful notion of social vulnerability, that is an outcome you can measure in very concrete ways and can be integrated. So I really think it's a, it's, it's a, it's, it's a matter of aligning, uh, this process that's underway and making it, uh, more focused, more attuned to avoiding inequitable outcomes. And I, I think the, the paradigm itself doesn't stand in the way. It's just that we need to be intentional about it and have attention to detail, really.

Speaker 2:

So, going back to our overarching, um, topic, um, the SE for this particular session, are there ways in which institutional decisions perpetuate racism, bias, um, and lack of equity in healthcare? I mean, we're, we're all talking about sort of on the, the, um, you know, how to fix it, how to improve it, how to change way. But what are some examples of decisions and decision making, um, other than those that we heard from, um, uh, raia with respect to workforce? Are there other decisions in the healthcare, uh, equations that perpetuate racism, that perpetuate bias with respect to the delivery of care? Melanie?

Speaker 7:

So I, I'm gonna answer, I'm gonna be a typical lawyer. I'm gonna answer your question, but maybe not answer fully the call the question. Cause there was another point I wanted to make that's tied to that. I represent a different part of, I think, an important player, um, in the continuum of care. And that's the, the pharma industry. Um, and I think, uh, one of the ways in which we have acknowledged, um, as a company that we had been playing into, um, the bias, the racial bias, is that historically for our clinical trials, we were going to the same players time and time again because we had relationships with those individuals, with those institutions. And we did not have a broad reach and to communities of color where, you know, in order for us to truly meet our ambitious goal of, you know, delivering healthcare options for all patients, then we have to study healthcare in all patients. And we weren't doing that because we were going to a very narrow segment of, you know, the healthcare, um, population. And so I think that was one way we were inserting bias in a way, is because we didn't really know how effective some of our drugs were. Breast cancer, for example, were efficacious in the, in, in black women, which we know the disproportionate number of our, of black women, you know, died due to, due to breast cancer. Um, and so one of the ways in which we course corrected, um, and I'm so excited to hear some of the speakers talk today, was around, you know, being vulnerable as a company to realize we don't have all the answers. And so we started to engage with community leaders across the United States who are addressing, um, you know, advance, advance, how to advance inclusive research, um, and how to address the biases in research. And also tapping into the local communities to understand how do we increase participation by black and let next, um, patients, how do we engage with physicians in these communities? And if there is a knowledge gap in terms of how to participate in re clinical research, then how do we help close that knowledge gap? And so really moving from a paternalistic point of view to a more to of say's still some paternalism there, we have a ways to go, but we are working on that to a more, um, leaning in with curiosity and learning from the communities themselves in terms of how do we better reach, how do we expand our scope? And then also in creating new KPIs for our, our clinical trial teams. You know, they were incentivized by going fast. Um, and then now we're saying how inclusive are clinical trials? How inclusive are protocols? Are our protocols automatically designed to exclude certain, um, ethnic groups because we might automatically, you know, have higher, you know, percentages, uh, of different things that might be part of the exclusion criteria. And really trying to take a whole multidisciplinary approach to increasing inclusion in our clinical trials. So, um, from, you know, the, the, the incentives internally as well as the outreach externally. So I just wanted to add that perspective because I think the pharma med device industries are important players in, in increasing, um, or I guess increasing equity in the continuum of care. So,

Speaker 2:

And Melanie, if we could stay with you for just a minute, I, uh, I'd like to ask if, if, if, and, and thank you for contributing your, your company's, uh, process in, in examining self-examination, I think is, is what was required. But what about the rest of your industry is, is this also a, a, a dawning, uh, uh, uh, happening, uh, across the pharma industry?

Speaker 7:

It is. I think it's slowly but surely happening. I think more and more companies realize that, um, you know, it's an imperative and, and you know, that as an industry that we definitely have to address our, our practices. So, you know, you start to see more, um, there's a trade association called pharma, um, and they've brought different members of industry together to talk about what is our stance on inclusive research? How do we address health equity not just in our research practices, but also in our other business practices. So that's another area where you're starting to see others in pharma, in the pharma industry and med device industry come together. I think Covid also highlighted, um, why it's imperative for us as an industry. Um, but I, and I, but I think we have such a long way to go, right? I think this is the first step in the right direction. Um, you know, our c e O and other CEOs are starting to make very vocal active commitments, and not just talking the talk, but walking the walk, um, to really, um, increase, um, the impact that we can have in addressing equity in healthcare off field.

Speaker 2:

Thank you. I really appreciate that. Thank you, Melanie. And Ed, you've got an active and, and quite connected and, and long, uh, set of questions in the chat. So I'm gonna invite you to come forward, um, and share.

Speaker 8:

Yes. Uh, well, thank you. I, I've been appreciate I appreciating this conversation. Um, I, I was a state health officer for seven years and really looked at all of the social issues and, and we, in trying to build an equity in everything we did, we set up a, a theory of change about organ around community organizing, organizing the narrative, organizing the resources, and organizing the people. And we decided in each of those areas, we had to ask specific questions on every single policy and every decision that we made. And so what I put in the chats were the questions that we asked with every policy decision, every programmatic decision that was made, who's benefiting, who is left out, what worldview do you bring? Do you bring that whole worldview of an individualist individual responsibility or community perspective? You bring it from a white perspective or a more diverse and inclusive InSpec respect perspective. And so those were the questions that we put, and it really actually changed how we did our work at the state health department. And it is having impact through Otter State in Minnesota.

Speaker 2:

Great. Thank you. And, um, uh, again, in the chat, um, a I believe critically important, uh, suggestion by Vaughn about the fact that maybe we think about changing medical education. Do you wanna talk a little bit more about that?

Speaker 6:

Yeah. You know, this is something, because I did a lot of work and when I was in practice, um, with G M E, I got to see what, what the criteria were for professional competence. And they never thought about or talked about equity and, and, and sort of what it means to treat patients from an equity perspective. And the more I look into this, and the more I do research around it, you think about what are, how are we even taught what constitutes professional practice? How, how are students, med students taught, you know, how to engage with patients and how to interact with communities and to the mo to a great degree, they aren't taught that, right? You know, there's a bias and, and sort of a racist perspective built into a lot of the curriculum that has never been challenged, right? And, and we're at a point now where I think we need to challenge those things because I cannot expect someone to do better if we haven't taught them any better. And so when we think about what are some of the ways that the we as institutions, if we are running training programs, if we are, you know, delivering medical education, have those equity questions that Ed put in here, are those a part of the way we design our instruction and our curriculum? Have we even considered how those things impact? And if we haven't, we really need to get on that if we wanna have the kinds of significant impact on shifting the way healthcare is done.

Speaker 2:

Great. Cindy, do you have a hand up? I'm, I'm seeing your hand up. Is that for time?

Speaker 9:

No, no, not for time. Okay. Um, it, I had a question that I, that I wanted to ask, uh, Melanie and others. Um, we've all heard and, and seen, you know, the, um, historical hesitancy and concern that many diverse communities, um, share because of sadly, you know, horrifying things that were done to them in the past. You know, we all know about what happened at the Tuskegee, uh, you know, institute. So how do you, how would you all suggest ways to break through that concern and that hesitancy and, and help them help those communities recognize that? Um, not in a paternalistic manner, because I think that's probably the worst thing we can do to say, oh, don't worry, everything's fine. We're treating everybody the, you know, well now, but how do you really break through that and try to get the diverse community to recognize it is okay to participate in a clinical trial. I will be treated just like everyone else who's participating in it. Um, I actually have a client that's got a multi-site, you know, clinical trial organization that was very involved in, um, the covid vaccine trials and, um, was working hard to try to bring in more of the diverse community into their database of patients. Cuz as you said, Melanie, they kept going back to the same places all the time and they want to try to expand that. Thank you.

Speaker 7:

I'll start, but I don't know that we have the perfect solution. I think it's about, I mean, we're operating at a significant deficit of trust still to this day. Yeah. You know, I think, um, you know, from participating in clinical trials all the way, just the relationships that they have with their healthcare providers in and of itself, I mean, it kind of goes back to the point Vaughn was raising that there is still this bias<laugh>, um, that healthcare providers have. Um, and it impacts their relationships with their patients. And then the removal of institutions from communities so that they no longer are able to build relationships with their providers. You know, they only have these urgent care centers or, you know, now they're only seeing doctors through the er. Like that's just completely eroded, you know, the old concept of having a relationship with your family physician. That being said, I think one of the ways that we are trying to, um, to overcome this hurdle is by the relationships that we're building with community leaders. So it's kind of one leader at a time, uh, one community at a time and, and trying to establish that trust, um, and, and talking more about the benefits and the value of, uh, diverse participation in our clinical research and leveraging those thought leaders and those who, you know, know the community and know what will most, what will go well, what will, I guess, what information the communities will receive better is, is the way we've found the best way we found to be effective and impactful. Um, and then by storytelling, you know, by having people who've participated in those clinical trials and their positive experiences on those journeys, I think has also been impactful for us as an organization. Um, but I think those are just, you know, continuing to engage. I mean, I cannot emphasize how much we have come to learn and really value the importance of community engagement at all different levels. Um, and it's one, one<laugh>, one relationship built over at, at a time.

Speaker 10:

I would like to add to that because, uh, you know, when when the pandemic started, um, certain agencies, you know, we were meeting n I h and all these folks and they're like, what do we do? How do we, um, you know, how do we get people enrolled in trials? And, and I was, you know, they're looking at the native and black community and we're like, we ain't got nothing for you here. Um, and you know, and they're like, but we need the data. We need it now. We need to figure out how the vaccine Okay. But what they say, you know, kind of, you know, what I said was like, it's too late if you're trying to build a relationship right now during a pandemic, it's too late. You should have built these relationships a long time ago. And so yeah, it is gonna be too late. And if they do wanna have better, um, trials, it does take a true systemic commitment, I believe, um, to, to really engage the community because I mean, I, I grew up in the black community. I represent the native community. Both of those communities are telling me, I don't care what you're saying, Francis, I'm not taking the vaccine. Um, and so I think a lot of it has to do with trust and, and building it over time and not just when, um, you know, they wanted trials. Cause I think that's for my community anyway. That's how it looks like, oh, now you want me engaged in trials? Yeah, I'm not gonna take that. And, and it, and Tuskegee came up a lot for that. Uh, and you know, they used to, um, you know, sterilize native women in I hs in the I h s system, the same system that we're working in today, um, is is how they were sterilized. So some community is like, you know, some folks are like, no, I'm not gonna, I'm not doing anything with the trial<laugh>. You know, and I think that that is gonna have, that's gonna take I think a lot of time to dismantle the lack of trust that our communities rightly so have with these systems. So I think, yeah, community engagement is key. Um, and, and it's still, even with that, it's gonna be hard, I think.

Speaker 2:

Um, well thank you Francis. And on that note, we are getting close to our time and I think we're about a minute out. Um, so I would ask if anyone, uh, has a last comment, uh, for this very interesting session. Great. Well, with that, I will turn it over and I'll turn it back to Cindy and the next person.

Speaker 1:

Thank you for listening. If you enjoyed this episode, be sure to subscribe to a H L A speaking of health law wherever you get your podcasts. To learn more about a H L A and the educational resources available to the health law community, visit American health law.org.