Dear Digital Health Startup - Lets talk about Health Equity

On the 15th of June HealthIL is holding a free virtual event on Health Equity.

The event is for healthcare organizations (providers, payors, corporate partners, and governmental entities) to meet a curated group of startups that are directly addressing defined challenges in Health Equity.

Any healthcare organization is welcome to participate. Any startup that has a solution that can address one of the specific challenges is welcome to submit their solution.

All details (including registration and submission) can be found here: https://www.healthil.org/health-equity

This post is inspired by the event.?

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There has been a lot of recent interest in Health Equity. Multiple outlets have cited Health Equity as one of the big trends in healthcare for the coming years. In addition, more and more startups are mentioning Health Equity in their decks.

The thing is, Health Equity is exceedingly complex, and teasing out where technology can help, and where it cannot help, is critical.

Therefore, for any founders (or funders) who are looking to convert Buzz Words to Actions in the Health Equity space, it is important to understand the underlying factors.?

Background

Healthcare systems around the world face large, persistent, and growing disparities, which create significant challenges to attaining health equity across many dimensions: geography, gender, socio-economic status, education, culture, race, or medical condition.?

It is very hard to categorize causal factors driving health inequity because there are so many overlaps. But we will try anyhow ---

There are four main aspects of health equity, which frequently overlap to create predetermined circumstances.??

• SOCIAL ASPECTS of health equity refer to how society influences a person's or a group's health. This includes how social norms related to ethnicity or gender can influence health services, as well as how lifestyle choices can influence health. Among social aspects of health equity, there are prominent subcategories: ethnic/racial gaps, sex/gender gaps, gaps between minority groups, lifestyle gaps (physical activity, nutrition, smoking/drinking/drug use) and other personal factors.
• ECONOMIC ASPECTS refer to factors that impact an individual's or a group's financial situation, such as access to capital or financial support. Time and time (and time and time ) again we have seen that economic status is a strong predictor of health, pretty much across all ages and medical conditions. Individuals and groups with poor economic standing have a difficult time accessing quality health care and maintaining good health. Education is also a factor and closely correlated to economic status, specifically regarding general knowledge, health awareness, and health literacy.?
• ENVIRONMENTAL ASPECTS of health equity pertain to the physical and built environment of an individual or group, and their impact on health. This can include things like distance from a medical center, public transportation options, lack of quality food/nutrition options, and polluting hazards (radon, noise pollution, carcinogens, lead, air quality, particulate matter, etc.) Environmental factors are intrinsically connected to economic factors, as wealthier groups can live in areas with better environmental factors.?
• STRUCTURAL ASPECTS refer to existing laws, regulations, policies, procedures, governance, or norms that may adversely affect one group or another. Among them is persistent effects of racial segregation, implicit or explicit discrimination against a particular group, language barriers, or cultural standards.

The Role of Startups

Tackling health equity is with technology is NOT about just digitizing current care – it is about maximizing the potential of technology to improve current care models. Tech is only one component, and technology alone cannot fully address health equity. Without major structural, economic support there will not be real change.

?That being said, there are definitely areas where startups can play a more prevalent role:

• Social aspects: Preventive care, personalized medicine, and lifestyle/wellness/mental health can have a noticeable impact in addressing social aspects of health inequity. ?
• Economic aspects: This is an interesting space for fintech solutions that address expenses, but also health education and advocacy solutions.
• Environmental aspects: The whole remote care world can fit in here: monitoring, treatment, tracking, diagnostics, and decision support. There are even unique mobility and logistic solutions that could be relevant.
• Structural aspects: Data interoperability and explainable AI solutions that can highlight structural discrepancies or biases in care, or integrate between disparate care providers, have relevancy here. Communication tools between patients and providers, especially multilingual and plain-language solutions, are also beneficial. Finally, solutions that increase agency for marginalized populations can also be relevant.

How to play in the Health Equity space?

There is a big gap between startups who are actively pursing health equity aims and those who are paying lip-service to health equity, much like there is a big gap between hype and viable opportunity in the larger health-tech space.

I have written a lot about the practical aspects of health-tech, so let’s zoom out and look at this at the high level…??

Targeting specific groups and their needs

One of the key aspects of health equity is the fact that not every demographic group approaches healthcare in the same way. Different cohorts need different types of care for different reasons and interact with healthcare systems in different ways. Different cohorts may have different clinical/medical needs as well. For example, kidney disease has major discrepancies across ethnic lines . Unpacking why is a whole other story… ?

For those who are exploring this path, it is important to deeply understand the unique needs of your target user base / demographic. Mae and BabyLive are two startups who have a keen understanding of the major gaps in maternal care for Black women in the US and are actively building solutions to address the gaps. MiSalud is addressing the linguistic and cultural gaps that exist in the LatinX population.??

Understanding economic incentives

This is complex, and is also where most founders struggle. As KP Yelpaala from InOn Health mentioned recently , marginalized communities typically are the biggest cost drivers to healthcare systems. Therefore, you would expect healthcare systems to more aggressively pursue health equity aims with the goal of reducing overall healthcare expenditure. Unfortunately, the competing economic incentives between stakeholders, especially in the US, means that founders, and funders, have a hard time building viable economic justification for Health Equity.

There are two ways to approach this issue. One is to look at this from the high level based on the incentives of the various stakeholders who interact with the product. This can help tease out the potential value-add for each stakeholder and the business model. CityBlock is an interesting example of this approach – where they have taken on all the risk and misalignment of their stakeholders by creating their own internal VBC black box.

Founders can also approach this from the perspective of the users themselves by understanding their economic motivations and limitations. Spora Health is an example of this approach, where they built a model that has a D2C component to align with the economic realities of their un-insured and under-insured user base.?

Holistic approaches???

Health Equity has so many different factors, many of which are unrelated to the actual practice of medicine in a hospital/clinic setting. This means that there is opportunity to build cross-vertical solutions.

LiveChair is an inspiring example of this. LiveChair has built an app that encourages and inspires users to be more engaged with their health – but with the active involvement of barbershops. This is unique because barbershops are an active and integral component of predominantly Black and African-American communities in the US, and LiveChair aims to increase health awareness and prevention via this unique community-engagement model.

Another example is UniteUs . UniteUs addresses the fact that the front door to healthcare for marginalized populations is frequently though community social care, and that many health outcomes depend on factors beyond the four walls of a hospital or clinic. In addition, the data that is so frequently critical for effective continuum of care is typically siloed between social services and the healthcare systems.?

A Note on Regulation

Governing bodies and regulators are starting to take a more serious approach toward addressing Health Equity, which can offer opportunities to founders. In order to recognize the opportunities that can emerge from regulation, it is important to understand the trickle-down effect of regulation on healthcare systems.

For example, Executive Order 13958 from June 2021 directly addresses equity, including healthcare. The Order states that Federal agencies shall "Identify strategies to advance diversity, equity, inclusion, and accessibility, and eliminate, where applicable, barriers to equity, in Federal workforce functions, including:?recruitment; hiring; background investigation; promotion; retention; performance evaluations and awards; professional development programs; mentoring programs or sponsorship initiatives; internship, fellowship, and apprenticeship programs; employee resource group and affinity group programs; temporary employee details and assignments; pay and compensation policies; benefits, including health benefits, retirement benefits, and employee services and work?life programs…? (emphasis mine).

There is even a bit on the use of technology. Section 5 states: "The head of each agency shall take a data-driven approach to advancing policies that promote diversity, equity, inclusion, and accessibility within the agency’s workforce".

CMS, a federal agency, has subsequently taken the call and recently issued the first change in reimbursement policy that directly addresses health equity ; and they are looking to issue more . ??

Founders, and funders, should spend some time understanding how regulatory changes affect stakeholders, and which stakeholders have renewed financial incentives to pursue Health Equity.??

Summary and A word on Global Opportunities

Health Equity is exceeding complex, but more and more organizations around the globe are starting to take baby steps to actively address the issue, and not just pay lip service to the issue. In addition, the world is large, and there are many opportunities beyond just the US. For example, the maternal care for Romani women in eastern Hungary shares many similarities to the maternal care issues faced by Black and African-American women in the US, which could be an opportunity for Mae and BabyLive. The Institute of Health Equity in the UK is actively working with the NHS on building holistic, multi-partner approaches to tackling the issue, which could present an opportunity for platforms like UniteUs.

Even though technology alone will not solve the problem, I am convinced that technology can definitely play an active part in promoting Health Equity. I am also convinced that founders who are diligent in understanding stakeholder motivation, economic incentives, and global opportunities will find a path toward viable businesses as well.????????????