Quantifying Health Care Injustice Is Important, But So, Too, Is Quantifying Health Care Opportunity

I recently read an article about a proof of concept attempt to craft a “Health Equity Summary Score” that could be used to “promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible (DE) enrollees in Medicare Advantage plans…” by using stratified point-in-time and improvement measures of clinical quality and patient satisfaction.

Leaving aside the merits and limitations of the study – there are many in both buckets, and it’s worth reading! – the core question of how the health care system can “promote and incentivize” health care equity is crucial and begs the even more fundamental question:

“Will eliminating health care disparities mean we have achieved health care equity?”

My answer? “No.”

First, even if we eliminate avoidable, unjust, and systematic differences in health care it doesn’t necessarily mean there will be no residual differences between groups. Patient preference, cultural norms, subjective ratings of satisfaction, etc. could contribute to residual group differences without being “unjust”. That is, we might never get to zero.

Second, stratifying our current quality measures by relevant social risk factors won’t capture all the places where inequity could exist. That is, if we “close the gap” on 100 measures, what about the gaps for the 100 things we aren’t measuring yet?

Third, and most important is that measuring health care injustice is not the same thing as measuring a state of equitable health care opportunity. It’s a pretty good indicator, but the terms are not synonymous.

If we want to promote and incentivize health care equity, we must come up with a way to measure it.

To my knowledge, and despite the efforts detailed in the article referenced above, no such measure currently exists. Here are some thoughts on how health equity scientists and scholars might approach it.

1.      Meaningfully engage patients and community members in the development of health care equity measures. If we want to know what a “state of equitable health care opportunity” might feel like, we need to ask the experts. It might even be something as simple as “When you came to the hospital today, how certain were you that you would receive the same quality of care as everybody else?”

2.      Map those measures onto health care processes. It’s one thing for patients to feel they have an equitable opportunity for quality health care, it’s another to demonstrate that they actually did have such an opportunity.

3.      Recognize that for the health care system to get to health care equity, we might need to incentivize the process and not just attainment of the outcome. For example: Does the health care facility employ community health workers or navigators? Does the EMR system allow for easy stratification of patient data to identify potential inequities? How many languages are spoken and how readily available are translators? While the goal of equity is long-term, incentivizing the adoption of near-term tools and resources is urgent work.

This isn’t an either / or proposition: We should track health care inequities at the same time we measure the presence and success of efforts to foment equitable health care opportunity.

But if we fail to keep our eyes on the prize, a narrowing of gaps might not translate into the lived and perceived experiences of our patients, families, and communities.