Health Equity Accelerator at One Year: Lessons Learned and Next Steps
In November 2021, after more than a year of investigating the racial health disparities across its organization, Boston Medical Center launched the Health Equity Accelerator, a radical system-wide transformation to improve health outcomes for BMC's Black and Latinx patients. And while changing the healthcare paradigm is incredibly complex everywhere, city safety-net hospitals confront additional challenges.
"Institutions that tend to serve BIPOC populations are also the least resourced organizations," writes BMC President and CEO Kate Walsh in a recent article published in Frontiers of Health Services Management. "And yet, they are also the ones that need to make those additional investments to deliver equitable care."
So, precisely what does it take to close racial health disparities for good?
On the first anniversary of BMC's Health Equity Accelerator, co-executive directors Thea James, MD, and Elena Mendez-Escobar, PhD, MBA, share their insights on building and implementing a radically new vision for healthcare — one they believe is not only achievable in Boston, but also for other hospitals across the country.
Health City: What have you learned about the root causes of racial health disparities that have informed your work with the Health Equity Accelerator?
Thea James, MD: I have learned that dismantling a dominant narrative requires having context, historical insight, to generate change. A quote I read in Health Affairs says it best: "Systemic racism is so embedded in systems that it often is assumed to reflect the natural, inevitable order of things." But that said, collectively at BMC Health System, we have absorbed and learned very, very quickly. I’m deeply proud of our health system for that.
Our insight is influencing how we act, innovate, and what we do. This is not a one-off project; this is a system transformation. We expect our intentionality to transformation will manifest in our forward data and outcomes compared to our 2020 baseline internal look over time. We have every opportunity to model for the country, to show what operationalizing an intentional strategy for health justice looks like and what it can achieve both internally and in our communities.
"We have every opportunity to model for the country, to show what operationalizing an intentional strategy for health justice looks like and what it can achieve both internally and in our communities."
I think we can also influence policy. I can imagine target allocation of healthcare dollars with accountability and an intended expectation of impact toward transformation — manifested in data outcomes, qualitatively and quantitatively. Each waiver seems to evolve as our overall national awareness has evolved. I think we have an opportunity to further positively impact reimbursement as well.
With respect to the root, the root is economic exclusion, largely caused by redlining. It has been perpetuating for BIPOC populations by preventing individuals and local community economies from reaching their full potential. This has impacted us as a mission-based healthcare system because those community residents are forced to prioritize survival over health. Predictably, redlining maps match the COVID-19 maps with respect to which populations fared worse. Our hospital was deeply impacted. But we are on a path of learning, teaching, partnering, and transforming. We are focusing on assets versus deficits among our patients and communities
As a community anchor, we have the power to have transformative impact there through intention in how we hire, invest, and procure.
Elena Mendez-Escobar, PhD, MBA: We have also learned the importance of approaching this work with humility. This isn't a provider-level problem, as clinicians often try to work with patients to coordinate care with their needs, but it's systemic to the healthcare industry. Traditionally, health systems have focused on asking patients to trust them, to engage more and strictly follow care plans that were often built with limited patient input and, often, a lack of understanding of their personal circumstances. Establishing a diagnosis and care plan takes multiple calls and visits with different specialist, which require both time and transportation. Patients can't always take that time off work or don't have childcare to meet this expectation. We can't put the failures of our health system on the patients.
We are so proud that multidisciplinary teams across BMC working to advance health equity are putting incredible emphasis on this: They are constantly seeking their patients' partnership to redefine care to meet their goals.
HC: How is racism perpetuated in the health care system today?
TJ: In my perspective, medical school has a primary focus on disease — which is very important. But in this traditional model, there's a missed opportunity to teach physicians to intentionally engage with patients and understand the full context for their disease. This includes their ability or resources to manage or prioritize their disease, in addition to other nuances of the human experience that affect their health status.
Patients and providers can have priorities that are not aligned. Without context, interpretation of patient decision-making can be pejorative when, in fact, they are most often making very rational decisions — decisions that reflect having to prioritize survival over health. This is a barrier to achieving successful clinical outcomes. This can also impact future physician-patient encounters and physician decision-making.
EME: One way we are learning bias and racism impact health outcomes is by obstructing interpersonal communications in ways that can result in delays in diagnostics or initiation of treatment. Research across the country is showing consistently how, in the absence of strong processes and timing guidelines, BIPOC patients consistently receive diagnoses when their disease is at a more advanced stage and take longer to start treatment. Putting focus on timing metrics and be an effective way to mitigate some of these inequities
HC: It has only been a year since the launch of the Health Equity Accelerator, but how would you say it is helping to dismantle systemic barriers and combat racism to improve health outcomes? How is it making a tangible difference so far?
TJ: In year one, the Accelerator is operationalizing an awareness about structural racism in general and placing a spotlight explicitly on how it manifests in healthcare. There is an ecosystem in place to support the work, awareness, innovation, education, and accountability.
From a tangible perspective, we as a healthcare system successfully sought and uncovered disparities in distinct areas across our enterprise. In 2021, six work groups were established and tasked with addressing these disparities, over the next one to two years. The work groups have been held accountable through dashboards and reports to an oversight committee. In the past year, the groups are already achieving tangible outcomes, leveraging internal and external partnerships.
All of this work occurs with a cadence, which enables us to measure the impact of our interventions against the disparities we identified. It will contribute to helping us evaluate our true transformation.
EME: We have gained significant insight into both the obvious and subtle ways that our health system perpetuates inequities. There are five lessons we are gleaning from our work:
- Wealth is Health — poverty continues to perpetuate poor health outcomes, and we are working in partnership with the community to create more pathways to economic mobility.
- Time Is a Luxury — many patients can't set aside the time and travel required by traditional health systems, so we need to make care more accessible and convenient.
- Agency Is Essential — patients need culturally and linguistically appropriate health providers and information to feel supported in their medical decision-making.
- Timing Is Everything — we have been able pinpoint where bias causes delays in treatment and build a portfolio of multicultural and bias training.
- Averages Are Blind —healthcare decisions need to be tailored based on the disease risk of your patient population, not on national averages.
An example of all these elements in action would be the Accelerator's work to reduce pregnancy and childbirth complications among Black patients. Preeclampsia is a leading cause of maternal morbidity and mortality. In the U.S., 1 in 12 to 17 pregnancies is impacted. But for Black patients in our hospital, 1 in 8 will develop preeclampsia. So, it's more important to talk to our patients about it than at the average hospital.
Thanks to the work of our Equity in Pregnancy team, including clinical leads Teju Adegoke, MD, MPH, Tina Yarrington, MD, FACOG, and program manager Giavanna Gaskin, we've made great progress understanding and addressing these disparities. We now know there are racial disparities in how quickly people get diagnosed with and treated for preeclampsia. So, we're proactively monitoring everybody who's at risk. From the first pregnancy appointment, we initiate a conversation about why they may be at risk, what that means, and what they can do to stay on top of it. We are leading an exciting remote blood pressure monitoring intervention for at-risk women. Enrolled patients establish a relationship with the nurse. They're able to text her. This gives patients a lot of agency in their health and adds the convenience of staying at home versus frequently traveling to the hospital for blood pressure checks.
HC: What are the priorities of the Accelerator in the next year?
EM: We continue to be focused on advancing Equity in Pregnancy and have recently launched Equity in Diabetes and Equity in Cancer. We also have two important priorities beyond our clinical areas of focus: expanding our equity research and community engagement work.
TJ: Although we are nascent in launch and scale, and Equity in Pregnancy is farthest along, we will begin to look at data in areas where substantive interventions have begun and compare it to our starting disparity data. We will likely develop new types of measurements and evaluations for tangible outcomes.
I expect our equity research infrastructure will escalate next year, given that we have filled previous staff gaps. We also have new, significant external system events planned for 2023 that we are looking forward to. Community engagement has been powerful and will continue to evolve and fuel our impact.
This interview has been edited and condensed for clarity and length