Five key actions for equitable access to care

What’s trending: Health systems aiming to address health equity are focusing on better access ?

One of the most fundamental elements of delivering healthcare is ensuring timely, convenient, and affordable access. Yet most health systems struggle to do this well—as evidenced by long wait times, care deferred, and universal patient frustration.??

Nowhere is this felt more than among patients from under-resourced communities.??

As the industry grapples with its health equity evolution, health system leaders are finding ways to ensure equitable access to care for all demographic groups their organization serves.?

Why it matters:?

Even among organizations that have smoothed access for other populations, most organizations still fail to provide equitable access to patients of all racial, ethnic, cultural, and socioeconomic backgrounds. Yet reducing disparities and increasing access to quality care is both a moral imperative and a strategic business solution. Health inequities cost the industry nearly $320 billion and, if left unaddressed, could skyrocket to $1 trillion in annual spending by 2040.?

Offering timely, affordable care close to and easily accessible by all communities is an essential goal for health systems. But challenges abound. Some of the most common issues include:?

1. Systemic barriers. Many deeply entrenched barriers fall outside health systems’ traditional purviews. For instance, food insecurity and insufficient means of transportation are two major limitations to overall health and the ability to access care.? ?

Consequently, health systems have to be careful even with well-intended efforts to improve access and understand how they will impact communities that have been marginalized in particular. For example, predictive analytics models are a popular tool to reduce patient no-shows and last-minute cancellations. The models use machine learning and data mining to forecast the future behavior of patients. On the surface, predictive modeling can help optimize clinician capacity and scheduling efficiency. But if health systems establish policies to improve show rates based solely on surface-level findings, they may simply penalize patients who need care most. ? ?

At one health system, the model worked well to identify patients with high, medium, and low risk of not showing. But when the health system analyzed the data more deeply, it discovered some of the most common reasons patients didn’t show were related to nonclinical social needs, such as inadequate transportation, lack of childcare, and inability to pay co-pays.? ?

2. Healthcare deserts. Many communities lack sufficient access to primary care, mental health care, and critical specialties, such as obstetrics and cardiology. Patients in these communities face a difficult choice: Either travel to another community for care (often with great expense in time and resources) or forego care until their health problems become acute. ? ?

These “healthcare deserts” are most common in rural America . In fact, the federal government designates nearly 80% of rural communities as “medically underserved.” But healthcare deserts also are increasingly common in urban areas, where lower-income communities have few primary care and behavioral healthcare options, and patients often depend on emergency rooms for care. Some of the largest urban healthcare deserts are in New York City, Los Angeles, and Chicago.? ? ?

3. Standard compensation plans and scheduling practices. Compensation plans for employed providers may inadvertently favor scheduling patients with commercial insurance over those with Medicare or Medicaid. For instance, factoring in revenue contribution versus work production may lead individual providers to cherry-pick patients with more lucrative insurance plans. ? ?

Health systems may also create practices that restrict access for Medicaid patients. For example, one healthcare organization established a policy to restrict access for Medicaid patients to a few days per month. In this case, business leaders were concerned with poor reimbursement and high no-show rates. But the policy created a second-tier system for patients who already were most often burdened with chronic disease and impacted by social drivers of health. In addition to producing disparities in outcomes, this policy also led to improper utilization in the higher-cost setting of the emergency department.? ?

What’s next:?

Disparities in healthcare access touch the lives of individuals and communities in ways that ripple through society—impacting not only the quality of life but the very essence of what it means to live in a just and equitable world. Health systems can play a pivotal role.??

Focusing on the following action areas can help organizations advance toward providing optimal access to all people in their communities:?

1. Partner with other organizations to reduce or remove barriers to access. Health systems can’t address systemic barriers to equal access by working alone. Health systems can best address things like food insecurity, transportation limitations, and health literacy by collaborating with other providers and community-based organizations.???

Health systems can drive transformational change as a convener of organizations. In this role, the health system can influence, make economic investments, build trust, and share power among other entities that have a vested interest in improving economic, social, educational, and political drivers of health. These entities include corporations, philanthropic organizations, governmental agencies, health plans, health advocacy groups, and others.?

For example, several leading health systems in Chicago recently brought together multiple hospitals and community organizations to reexamine and redesign healthcare and social services on the south side of the city. The resulting coalition, the?South Side Healthy Community Organization , is a group of 13 healthcare entities, including safety net hospitals, larger health systems, and Federally Qualified Health Centers. The group first secured financial support from the state. Then, the group collaboratively redesigned the local healthcare delivery system to improve access to primary care and specialty services. The design also incorporated nurse care coordinators and social workers who could help direct patients to the right providers and coordinate services across multiple entities.?

Recently, the group?announced it would invest ?nearly $1 million in local organizations that provide stable housing options, nutritious food, emergency financial support, and transportation services to help members of the community go to and from medical appointments.?

2. Ensure a sufficient supply of mental health, specialty, and primary care providers to meet demand. Given the prevalence of healthcare deserts, health system leaders should consider their organization’s geographic footprint and how its sites of care are distributed within and across the market. That includes communities of color as well as low socioeconomic and under-resourced areas within its primary service area. ? ?

Alleviating healthcare deserts and expanding equitable access requires, in part, sustained commitments in the communities the health system serves, including place-based investments (i.e., resource commitments made within socially vulnerable zip codes).???

Health systems can also convene or provide direct services to further alleviate healthcare deserts. Key efforts can include economic development, affordable housing initiatives, educational pipeline and workforce programs, health advocacy and policy influence, racial and social justice partnerships, health promotion, and behavioral health programs.?

3. Address restrictive policies and equalize compensation practices. A consistent consequence of restrictive policies or practices is that access for patients from racially and socioeconomically disadvantaged populations—those who would stand to benefit most from medical interventions—becomes limited. This may result in delayed care and exacerbation of illness. ? ?

Although white Americans constitute the single largest racial group of Medicaid and CHIP enrollees, people of color across ethnic groups collectively make up a higher percentage of enrollees. Based on recent enrollment data , approximately 60% of Medicaid enrollees are from ethnic or racial minorities. As such, the collective access impact to communities of color can be greater, especially when also considering the social drivers of health that disproportionately impact these groups. ? ?

Health systems can protect against cherry-picking by equalizing the dollar value payment across all payer types and utilizing a relative value unit (RVU)-based plan.?

4. Ensure access initiatives don’t compromise access for communities that have been marginalized. For instance, with the example of using predictive analytics models for scheduling, health systems need to collect data about why patients aren’t showing for appointments. They also need to establish a way to act upon that information. Otherwise, disparities in care and outcomes are more likely to occur.?

For example, a new policy won’t improve show rates if it penalizes patients who no-show but fails to address the nonclinical issue. Studies show that 80% of health outcomes are shaped by these social drivers of health.???

One health system’s solution was to establish referral relationships to social service agencies, provide free transportation to and from patient visits through a partnership with Uber, and systematically track transportation needs data over time to inform future interventions.?

5. Create a specific access strategy for patients from communities that have been under-resourced or marginalized. Health systems are unlikely to deliver the needed impact if they haven’t established a cohesive strategy for helping achieve equity in care and outcomes.???

Organizations that effectively and intentionally address inequities related to access have targeted approaches to resource deployment, explicit goals, and measured performance. An example application is setting up health equity care navigators. These navigators assist patients in coordinating appointments, solidifying transportation, navigating financial barriers, and directing them to virtual care access points.??

One health system created a network of community resource centers that address many social needs, including support and guidance for enrollment in state Medicaid programs.???

Organizations should also factor equity considerations into their decisions about the location of ambulatory clinics, how they advance digital health assets (such as nurse triage lines and virtual provider visits), and how they develop their hospital at home model . These interventions and decisions should aim to increase access, reduce the need for in-clinic visits, and illuminate social needs they and their partners can proactively resolve.?

Even the best-intentioned efforts can produce negative results if not constructed with a specific eye toward the effect they will have on these communities. Additional strategies to better serve these populations in the health system are likely also necessary. By focusing on these five key action areas, health system leaders can advance access for all.?

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