Addressing Healthcare Disparities with Quality Improvement

In its 2021 National Healthcare Quality and Disparities Report, the Agency for Healthcare Research and Quality (AHRQ) defines healthcare disparities as differences between populations in the way they access, experience, or receive healthcare.

For centuries, the U.S. healthcare system has grappled with health disparities. Progress has been made, but these disparities persist today.

How can a healthcare organization reduce healthcare disparities in its member population?

One way is through the lens of quality. Focusing on quality improvement for the entire population served can help an organization create a system that will reduce healthcare disparity while improving quality for all.

In this article, we’ll explore:

• What is the current state of health disparities in the U.S.?
• What factors contribute to those disparities?
• How can quality improvement, especially in medication optimization, play a role in reducing those disparities?

Impact and Prevalence of Healthcare Disparities

According to the Institute of Medicine, health service disparities are differences in treatment provided to a group of people that are not justified by the underlying health status or the patients’ preferences.

In 2003, the Institute of Medicine (IOM, now the National Academy of Medicine) released the report: "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care". In the report, the institute highlighted the fact that ethnic minorities received a lower quality of care in the US and had worse health outcomes compared to White people.

Since that report, much research and work has been done toward reducing healthcare disparities. But health inequity persists today.

Impact of healthcare disparities

Healthcare disparities affect the health of the U.S. population and result in increased healthcare spending each year.

In one study published in the JAMA Network, researchers estimated that, in 2018, racial and ethnic health disparities carried an economic burden for the US of up to $451 billion, the equivalent of $1,377 per person.

The economic burden of health disparities for people without a four-year college degree was estimated between $940-978 billion, translating to $2,988 per person.

These estimates were based on the sum of excess medical care expenditures, lost labor market productivity, and the value of excess premature death.

This economic impact is driven by the underlying prevalence of health disparities across the United States.

Prevalence of racial healthcare disparities

In a survey from the Kaiser Family Foundation (KFF), one in five Black adults and one in five Hispanic adults report being treated unfairly due to their race or ethnicity while getting healthcare for themselves or a family member in the previous year.

In terms of healthcare access, about one-quarter (24%) of Hispanic adults and more than one in three (34%) potentially undocumented Hispanic adults reported that it was very or somewhat difficult to find a doctor who engages with them in a way that is easy to understand.

When looking at quality measures between 2015 and 2019, black people received worse care than White people for 43% of quality measures according to the 2021 National Healthcare Quality and Disparities Report, American Indian and Alaska Natives (AI/AN) population groups received worse care for 40% of quality measures, and Hispanics received worse care than non-Hispanic White populations for 36% of quality measures.

The report looked at hundreds of measures, including the rate of influenza vaccination in hospitals, asthma-related emergency department visits, colon cancer care, HIV care, and the rate of diabetes-related end-stage renal disease (ESRD).

Prevalence of sexual orientation and gender-based healthcare disparities

In terms of gender-based healthcare disparities, in 2022, one in ten (9%) of non-elderly adult women who visited a healthcare provider in the previous two years said they experienced discrimination because of their age, gender, race, sexual orientation, religion, or some other personal characteristic during a health care visit.

According to a 2020 survey by the KFF, LGBT+ people are more likely to report being in fair to poor health compared to non-LGBT+ people (23% vs. 14%).

In the survey, almost half of LGBT+ people (47%) reported a chronic health condition that required regular medical care, compared to 40% of non-LGBT+ individuals. Yet more LGBT+ people (or a household family member) had difficulties paying for their care in the past twelve months than non-LGBT+ people (30% vs 19%)

Health organizations need to address these racial and gender-based disparities to improve patient outcomes, well-being, and lower health costs, which increase when patients can’t access the care required and can lead to avoidable expenses, e.g., emergency department and inpatient visits. These actions will also help improve the overall health of the US population. Addressing these disparities starts by identifying factors that can lead to them.

Factors that Contribute to Healthcare Disparities

Several socioeconomic status and physical environment factors can contribute to healthcare disparities. These factors can be grouped into different categories.

Socioeconomic factors

Race, ethnicity, and language

According to the Institute for Healthcare Improvement (IHI), people from racial and ethnic minorities as well as people with limited English proficiency in the U.S. are more likely to experience an adverse health event. They are also more likely to have inappropriate and costly tests ordered, experience preventable hospitalizations, have longer hospital stays, and have higher hospital readmission rates.

Sexual orientation and Gender identity (SO/GI)

SO/GI is also a common factor contributing to health disparities.

LGBT+ people are more likely to report a negative experience with their providers compared to non-LGBT+ adults (36% vs. 22%). According to the Centers for Disease Control and Prevention (CDC), sexual minority persons reported a higher prevalence of severe outcomes from COVID-19 than heterosexual persons.

Disability status

Disability is another, often unrecognized factor that can result in healthcare disparities.

Adults with disabilities are four times more likely to report being in fair to poor health than adults without disabilities (40.3% vs 9.9%). These disparities can be explained by the fact that the U.S. healthcare system isn’t designed to provide the complex care required for adults with disabilities and presents significant barriers to care when a person with special healthcare needs transitions from pediatric care to adult care.

Education and income status

Other social factors influencing disparities include education and employment status, health insurance coverage, and low income.

People with higher education are less likely to report poor health, since education tends to lead to better-paid and more stable jobs, allowing individuals to accumulate wealth that can be used towards better health care.

Environmental factors

Housing, access to transportation, access to healthcare providers and pharmacies, and food security are also factors that can exacerbate health inequities.

Depending on where an individual lives, they can have limited access to healthcare services or healthy food, which can result in poorer health.

Access to a support system and social integration also plays a role in health inequities.

The Role of Quality Improvement in Addressing Healthcare Disparities

An effective way to address disparities is through quality improvement. Quality improvement interventions can reduce healthcare disparities either by targeting a specific group of people or by being universally implemented.

Reviewing current quality and safety performance according to the different populations a health organization serves can be a first step to identifying existing disparities.

Common stratification criteria include but are not limited to:

• Demographic criteria like race, ethnicity, or language
• Sexual orientation and gender identity
• Disability status
• Social determinants of health.
• High-stress neighborhoods or other geocoding

Once disparities are identified, organizations must understand their root causes to design effective quality improvement interventions.

Using quality improvement interventions to address health inequities enables organizations to monitor metrics and progress toward an equitable system.

For instance, let’s imagine a health organization identifies a disparity in diabetes care between its Black and White members.

Black enrollees receive fewer foot exams than their White counterparts, which results in a higher rate of diabetes-related foot complications in Black people.

By investigating further, the organization finds that the disparity isn’t due to under-reporting or fewer referrals for foot exams. Instead, it’s discovered that Black patients are less likely to use referrals because of the lack of public transportation next to the referral clinics and the high cost of the clinic parking spaces.

As a result, the organization establishes partnerships with clinics that are more conveniently located and encourages patients to ask for referrals to those clinics.

Diabetes foot care and assessment is a Centers for Medicare & Medicaid Services (CMS) reported measure. In this example, identification and careful investigation of this disparity through the lens of quality enable the organization to develop effective quality improvement interventions. These interventions lead to a reduction of the health disparity between its Black members and their White counterparts.

Quality Improvement Strategies to Address Healthcare Disparities

In its 2012 report about quality improvement interventions to address health disparities, the AHRQ reviewed different quality improvement (QI) interventions and their effects on disparities. Most QI interventions included patient education, promotion of self-management, and provider education.

For example, one program looked at the impact of QI intervention to reduce the disparities in the rate of biennial lipid profiles between African-American and White Medicare beneficiaries. After the interventions, the proportion of African-American beneficiaries with diabetes receiving a biennial lipid profile increased by 16.7%. The disparity in performance of biennial lipid profile was reduced by 9.8% between African-American and all eligible white beneficiaries.

Other interventions reviewed in the report included an audit of the current state of care and feedback to the care team, medication management, and disease management.

In one recent study published in the JAMA Network, researchers looked at the impact of interventions on the disparities in blood pressure (BP) control between Black and White patients of a large integrated health system.

The strategies implemented to reduce the disparities included provider training about culturally appropriate communication tools, patient storytelling videos, patient group sessions, and education about lifestyle changes (diet, smoking cessation, exercise, and weight reduction).

As a result, BP control disparity decreased by 3.8% (95% CI, 3.2%-4.4%) between Black and White female patients aged 50 to 64, and by 4.2% (95% CI, 3.0%-5.5%) between Black and White male patients aged 18 to 49 years. The interventions didn’t have the same impact on the different age groups, which shows the importance of understanding the nuances within a population before designing QI strategies.

The Role of Medication Optimization in Addressing Healthcare Disparities

While patients engage with their primary care and specialty providers periodically throughout the year, they engage with their medications multiple times per day. Medications are a critical component of a patient’s treatment, and yet many individuals are not on the most appropriate medications or lack the needed follow-up to ensure appropriate medication or dosing adjustments. Medication mismanagement results in $528B in avoidable healthcare expenditure per year, making effective medication management a critical element in improving health outcomes and reducing overall healthcare spend.

As with other areas of healthcare delivery, minorities, and underserved people experience reduced access to pharmaceutical care and worse medication-related outcomes than the rest of the population. They experience an increased risk of adverse drug events, a higher rate of medication non-adherence, or an increased risk of treatment failure.

For example, Black people are two to three times more likely than White people to die of preventable heart disease and stroke. While many different factors can explain this disparity, it’s important to note that effective control of high blood pressure among Blacks is less than in Whites (49.5% vs 53.9%). Uncontrolled high blood pressure is the leading cause of cardiovascular disease.

This disparity can be explained in part by greater medication non-adherence to antihypertensives in Black patients compared to White patients (24.3% for non-Hispanic whites vs 35.7% for blacks) according to a 2014 study of medication adherence in Medicare patients.

The reasons behind those medication-related outcome disparities are multiple. Possible patient-level factors explaining those disparities include:

• Misunderstanding of illnesses and medication use
• Language barriers
• Lack of trust in health professionals
• Income and health insurance status
• Geographic access barriers to pharmacies

Systems and provider-related factors can also contribute to these disparities. For example, providers' language skills, availability of translation services, and patient’s experience of patient-provider interaction can play a role.

Addressing these factors and ensuring all patients have access to medication optimization can help reduce these healthcare disparities.

In a 2022 review of strategies to improve medication adherence and blood pressure, authors found that using trained personnel, mobile health tools, or a combination of both were effective strategies to increase antihypertensive medication adherence and lower blood pressure in minority populations. Similarly, a 2022 meta-analysis showed that therapeutic alliance-based interventions improved medication adherence for Black patients who had both hypertension and diabetes.

How artificial intelligence-powered medication optimization can reduce health disparities: A Case Study

SCAN Health Plan

SCAN is a large non-profit Medicare Advantage plan serving more than 270,000 individuals in the Western and Southwestern states.

While reviewing the annual quality scores for the Medicare Advantage and Part D Star Ratings programs, the plan identified a medication adherence gap between their general population and their Black and Hispanic members, especially for their cholesterol, diabetes, and blood pressure medications.

After investigation, SCAN found that members with lower adherence didn’t always know the prescription benefits the plan offered (such as no co-payment for certain medications). There were also language barriers. Members with lower adherence had a difficult time understanding providers who spoke English too fast or providers who couldn’t answer their questions in their native languages.

Another common factor behind the gap in medication adherence was that members didn’t always understand what medications they were taking and how those medicines could help them.

Armed with that knowledge, the health plan went on to increase its outreach to its minority members by training more staff in cultural competence and pairing their members with culturally and linguistically matched staff.

SCAN also partnered with Arine to leverage the capabilities of their medication intelligence platform to:

• Identify underutilization of care by using member selection algorithms that overcame hidden bias.
• Pair members with the best clinical team members based on language and culture using automated workflow engines.
• Use culturally sensitive Smart Questions to better inform their interventions.
• Leverage algorithms to navigate members to lower-cost treatment options or the plan’s health resources in the community.

Using Arine’s AI-powered platform, SCAN was able to execute an efficient, targeted approach to member prioritization that streamlined member matching and outreach. The result was that the first outreach attempt a member received was from someone who spoke their preferred language and was more likely to understand the member in their cultural context. This approach helped to build trust with members who historically felt misunderstood.

In addition, Arine’s platform leveraged medication intelligence using AI to predict which members were likely to need additional support and suggested the next best action for the member’s care journey. Since the software platform provides medication-related problems, social determinants of health, and possible recommendations for intervention in real-time, pharmacists and technicians were able to spend additional time building rapport and counseling members they were interacting with.

As a result, the health plan shrank the medication adherence disparity seen in their Black and Hispanic populations by 35% in seven months. The proportion of days covered (PDC) for Black and Hispanic members increased from 50%-62% to over 80% in diabetes and cholesterol medications. This is just one example of how trained clinical staff using an AI-powered medication intelligence platform reduced the disparity in care for Black and Hispanic members.

Conclusion

Despite progress made these past decades, health disparities persist with minorities experiencing worse health outcomes than the general population. Framing health disparities through the lens of quality improvement is essential for health organizations to design effective processes to reduce these disparities

To improve the quality of health for all their members and advance health equity, health plans will need to address healthcare disparities that exist within their populations including those related to medication utilization.

Artificial intelligence-powered platforms, such as that offered by Arine, can enable health plans to understand the reasons behind existing disparities and use the insight gained to design appropriate interventions to reduce these gaps.

Learn more about how Arine can help your health plan improve the quality of healthcare for all your members.