How Health Care Leaders View Disparities in Care

Disparities in care delivery, driven by factors such as structural racism and social determinants of health (SDOH), are pervasive and can have a substantial impact on patient care. Many health care providers are tackling the difficult task of reducing disparities and providing more equitable care.

In a February 2024 survey of NEJM Catalyst Insights Council members — who are clinicians, clinical leaders, and executives at organizations around the world that are directly involved in care delivery — half of respondents report that disparities in care delivery are widespread, very widespread, or extremely widespread at their organization, and 59% indicate that patients are impacted, very impacted, or extremely impacted by these disparities (Figure 1).

Leonor Fernández, MD, is Medical Director of Health Equity at Beth Israel Lahey Health (BILH), an educator and internist at Beth Israel Deaconess Medical Center (BIDMC), and an Assistant Professor of Medicine at Harvard Medical School, in Boston, Massachusetts. She says that to eliminate health disparities, health care organizations must address the complex relationship between structural racism and SDOH.

“The challenge is that racism and SDOH are so structurally intertwined,” says Fernández. “When there is inequitable access to education, income and wealth, housing, transportation, insurance coverage, and healthy food, and that unequal distribution falls along race and ethnicity lines, it is not surprising that we see racial and ethnic differences in health care.”

The Covid-19 pandemic led to a heightened awareness of health disparities, she says. “There has been real progress in understanding the impact of racism and SDOH and great work done on integrating a health equity lens and strategies into health care delivery. The first step to fixing this issue is recognizing that there are real differences in care that, while unintended, are caused by how we organize and finance health care delivery, how we sometimes fail to address the needs of diverse populations, and also by implicit bias. Health equity goals have more traction now.”

Measurement of disparities is key to addressing them, she says. “Health systems and payers are learning how to measure and disaggregate health outcomes along race/ethnicity and SDOH lines. The key question is, how do we measure patient care disparities well enough that you can understand them and then actually do something about them?”

“We are most effective when we apply this knowledge across the entire organization in order to make change,” says Fernández. “You have to reimagine yourself as an organization to deliver more equitable care. For example, to be effective, we need to speak our patients’ language when we communicate with them, literally and metaphorically. Senior executive compensation metrics that align with equity goals are important. Everyone in the organization should have skin in the game and make equity a priority.”

Fernández says transparency in equity initiatives is also critical, citing the 2024 Beth Israel Lahey Health Diversity, Equity and Inclusion Progress Report¹ as an example. The report provides data for three broad objectives: Talent (having a workforce that mirrors the diversity of the communities that BILH serves for both leadership and care delivery roles); Patients/Health Equity (eradicating disparities in health outcomes within BILH’s diverse population of patients); and Community/Supplier Diversity (expanding investments in underrepresented communities to close socioeconomic disparities that impact population health).

Deneen Richmond, MHA, RN, is Chief Quality, Equity, and Population Health Officer at Luminis Health, and President of Luminis Health Doctors Community Medical Center, in Lanham, Maryland. She says that for many health care organizations, the events of the year 2020 accelerated their focus on eliminating disparities.

“I think 2020 was a pivotal point in time in the United States for having serious discussions about structural racism, discrimination, and disparities,” says Richmond. “Not just in health care, but across society at large. There was the murder of George Floyd and its impact on the national conversation about racism, and widespread health care disparities that occurred during the Covid-19 pandemic. It was a wake-up call for everyone, although we’re now 4 years out and not everyone has followed through on making necessary changes.”

Richmond mentions a February 2024 Commonwealth Fund report² as one of several studies showing that progress on disparities has been slow in coming. “This particular report focuses on health care worker observations of discrimination and bias in the care delivery process, and the data has been stratified by race. While overall the findings indicate the presence of discrimination and bias, they also show significant differences in perception along race and ethnicity lines.”

Like Fernández, Richmond says it’s critically important that health care organizations track the race and ethnicity of patients and health care workers. “People need to understand why we are asking about race in a health care context and that we are collecting this data because we want to eliminate disparities in care. You really can’t understand the full extent of disparities without stratifying the data.”

She calls for race and ethnicity to be included among the key metrics tracked by health care organizations. “There’s a lot of emphasis on measuring quality, but we need to rethink what the key quality indicators should be. Most organizations do not require stratified data by race, so they can’t begin to understand disparities and may not see the full extent of their impact. If you really want to improve quality and outcomes, what better place to start than fixing disparities?”

Richmond says that Luminis Health places a high value on eliminating disparities in health care and promotes workforce diversity throughout the organization. She says recommendations from the organization’s Health Equity and Anti-Racism Task (HEART) Force serve as the primary roadmap for these efforts.

Alexander Garza, MD, is Chief Community Health Officer at SSM Health in St. Louis, Missouri, and responsible for managing the impacts of SDOH and inequities in care delivery among the patient population. He says that fostering workforce diversity and increasing job opportunities in health care are important aspects of addressing disparities.

“I work closely with our HR [human resources] department on expanding workforce diversity as well as creating economic opportunities for underrepresented team members,” says Garza. “We’re currently focusing on recruiting people from economically disadvantaged communities and helping them gain access to the health care workforce, while also creating a path for them to advance their careers. For example, a new employee may be brought on as a certified nurse assistant, but we also offer a path to becoming a registered nurse. The goal is to provide stable employment and help those employees deal with financial challenges caused by SDOH.”

“We are also committed to examining our talent processes and programs throughout the team member experience to address real and perceived inequities that might exist,” he adds. “For example, we recently created a new career development program, FlexPath Funded, that provides upfront tuition for skill-based courses and degrees and certificates aligned with our workforce needs, thereby removing financial barriers to participation.”

Garza mentions several community health initiatives that are driven by organizational key performance indicators (KPIs). “There are a lot of programmatic things, such as building a dedicated system for evaluating SDOH impacts, and for our maternal health population we’re addressing food insecurity using a SDOH screening process and then referring them either to a food pantry or other resource in the community. There is also a broader effort to build food pantries in each of our hospitals and then use referrals out into the community to get sustained engagement.”

Garza says that SSM Health also uses a variety of KPIs in clinical care to mitigate the impacts of disparities, mentioning colon cancer screening as an example. “We looked at colon cancer screening and payer class and then examined how many men 50 years and older had completed a colon cancer screening that were on Medicaid or were uninsured versus the percentage that had private insurance. The goal is to narrow the gap in screening percentage.”