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174: Hospitals & Health Equity: What it takes to bring about real change in healthcare systems

It takes time, energy and financial resources to bring about change within an organization. Healthcare organizations are no exception. 

Health systems that are serious about centering health equity need to put their money where their mouth is, says compliance and DEI consultant Linda Howard. In practice, this means centering equity in both their mission statements and their budgets.

“You have to allocate resources. When people start seeing resources being allocated towards things, they start to take it more seriously,” Howard says. 

 

Howard speaks with Health Disparities podcast host Christin Zollicoffer about what it takes to bring about real, lasting change in health systems. They also discuss the possible compliance and legal consequences health systems can face if they fail to address health inequities, and why the investment in health equity is worth it.

 

This episode rounds out our 5-part series on Hospitals & Health Equity. Find previous episodes from this series by subscribing to The Health Disparities podcast from Movement Is Life on Apple Podcasts, YouTube, or wherever you get your podcasts.

 

Registration is now open for Movement Is Life’s annual summit! Find all the details at our website, and get signed up today!

The transcript from today’s episode has been lightly edited for clarity.

 

Linda Howard: You know for most healthcare professionals and most healthcare organizations, they came into the space because they wanted to help people and that is, you see that theme throughout people's mission and when you ask people, why did you become a nurse and why did you become a doctor? When you don't address health inequities, there is such a large portion of the population that you're not reaching. So just as a healthcare organization and as a healthcare practitioner, just from that personal mission statement, I think it's important.

 

Christin Zollicoffer: You're listening to the Health Disparities podcast from Movement is Life. I'm Christin Zollicoffer, a member of the steering committee at Movement is Life, and I'm also the chief belonging and equity officer at Lifespan, which is a partner and academic medical center with the Warren Alpert School of Medicine at Brown University. We've spent the past couple of months focus on the question, what role and responsibility do hospitals and health systems have in addressing the rampant healthcare disparities in our nation. If you've missed any of our recent episodes, I'd encourage you to go back and listen to the conversations we've had with phenomenal guests from the Commonwealth Fund, The Joint Commission, U.S. News and World Report and the Massachusetts Health and Hospital Association.

 

To round out our series we're going to talk about the real practicalities of doing this work of changing systems and changing organizational culture because that's what's needed to happen in order to truly put health equity at the center of operations. Today we're joined by Linda Howard, a consultant with many years of experience in healthcare compliance, DEI -- diversity equity and inclusion and health equity. Linda, welcome to the Health Disparities podcast. Thank you so much for being here.

 

Really quickly have a shameless plug before we dive in, we have a plug for Movement is Life's annual summit. This year's theme is Health Equity solutions from Healthcare leaders, the conference takes place in Atlanta from November 14th through the 15th. It's an incredible event, bringing together stakeholders from different and diverse backgrounds to discussing health equity challenges and equitable and actionable solutions. It is a very fantastic and engaging interactive summit. We hope you can join us. Visit our website movementislifecommunity.org for all the details. Okay, Linda ready to jump in?

 

Howard: I'm ready to jump in. Let's do it. 

 

Zollicoffer: So let's start off by, tell us a little bit about your background. How did you become involved in healthcare operations and compliance and what led you to focus on health equity?

 

Howard: Okay, so way back I was an attorney and then I moved in the to the healthcare space about 20 years ago. I started out in operations and then in healthcare compliance and I later started moving into diversity equity and inclusion just because there was such a great need for it and all so it was so much of my lived experiences of navigating law firms, corporate America, working in healthcare and just you know witnessing firsthand some of the things related to inequities and I started out focusing on DEI generally. But I started to narrow my focus and one of the areas that I've narrowed my focus to is health equity and it's just such a natural transition for me because of my years of experience in healthcare and understanding how healthcare systems operate. I've worked as a interim chief compliance officer for hospital systems. I've also worked as an interim chief compliance officer for patient assistance programs. I've worked on the health plans side, working with Managed Care organizations, accountable care organizations. So I've had the benefit of working in a number of different healthcare systems. I've also just had the lived experience of really dealing with the impact of health inequities. I am one of seven children, five of my siblings have passed, four of them, I will say to, you know, premature deaths that I directly tie to health disparities and health inequities also experienced that at a very young age with my father who had end stage renal failure. So when I, you know, take all of my experience in a healthcare space and just my life, it just has created this great passion for this work around health equity.

 

Zollicofffer: Linda, you know, when you're originally sharing your history, it's rare to have a DEI practitioner coming to the space having so much experience on the administrative side from compliance, and on the payor side, that's truly seeing DEI and health inequity from a different perspective because you're looking at the aggregated data. Then we you couple it with personal loss and personal experience and being able to see that first hand, let me first say, my condolences, that is such a strong experience to relive so close and proximate to your own person where you feel it you see it you can say, okay, this is not just large data. This is not just aggregated experience. No, this is very personal. This is one-on-one. So that's pretty impactful being able to come in and bring all of that experience together to DEI and health equity. When you think about systems level change, that has a cost. What's in it for Health Systems to make change happen?

 

Howard: Well, I think that there is a number of things. One, you can look at it as the right thing, the good thing from the moral side, for most healthcare professionals and most healthcare organizations, they came into the space because they wanted to help people and that is, you see that theme throughout people's mission and when you ask people, why did you become a nurse and why did you become a doctor? When you don't address Health inequities, there are so much such a large portion of the population that you're not reaching. So just as a healthcare organization and as a healthcare practitioner, just from that personal mission statement, I think it's important. Also there's, you know, looking at the impact that it has on communities and I shared a little bit about my story in terms of my family. But it's not just a patient that it impacts, but it does have an impact on families and it does have that ripple effect and it has an impact on communities, because individuals and families make up communities it have an impact. It has an impact on the productivity of the community. So from that perspective, it's real. Now you say for healthcare organizations, like what's in it for me? I talked to healthcare organizations and individuals looking at it from different perspectives. There is, you know, I put on my compliance and my legal hat and there are some serious compliance and legal consequences to not addressing health inequities.

 

For example, I know that the OIG recently in their compliance program guidance have to put a great focus on quality of care as a compliance issue and a lot of people don't make that connection between quality of care, compliance, and that can lead to organizations having violations of the false claims act, which is serious penalties associated with that. So when you look at issues of not being able to deliver culturally competent care to a patient population, that you are billing Medicaid and Medicare for, there's some serious consequences there. You also have CMS who is really starting to put a great focus on health inequities and in taking that into consideration and as it's doing its star rating for organizations. The Joint Commission also now has an accreditation related to health and health equity. So there's just that side of it from a regulatory, from a legal standpoint. You've had healthcare organizations that have had lawsuits filed against them for health inequity issues, one case was related to the use of artificial intelligence in the healthcare space and using algorithms that made determinations that populations, and particularly African-American populations didn't have the level of sickness to put them into certain programs, because what they did was they associated spending on health care with the degree of the illness.

 

And so it was a formula and as a result you had people of color who were not placed in needed programs where other groups of people were placed into those programs and that resulted in lawsuits. So there's a lot of implications that can happen when there is not a focus. And then I will just kind of wrap that up with just looking at, you know, some of the other issues just like just patient outcomes. There's just more adherence to treatment programs when there's culturally competent care, less readmissions, less claims against hospitals for discrimination. So, there's a host. I could probably take up this whole session just talking about all the benefits that healthcare organizations and healthcare professionals gain from focusing on health equity.

 

Zollicoffer: Absolutely and you've mentioned a few of those needed systems to motivate hospitals that is you know, NCQA looking at those quality measures. It is CMS. It is also Joint Commission and quite frankly without those accrediting and regulatory bodies, you know, coming in and mandating the requirements to set the infrastructure whether its data collection data standardization. It does make a huge difference. Without that push, I don't believe many health systems would have even embarked upon this journey.

 

So I really appreciate that and those are real costs associated and they do have a true downstream impact to creating a system not only that's beneficial for patients and communities but also for the health system in itself, we know that there's such thin margins, profit margins in healthcare overall. When you think of specific examples of healthcare organizations that successfully prioritize health and equity and the impact that has had, a few come to mind, who comes to your mind?

 

Howard: I haven't worked with them personally, but I have read studies and Kaiser is one of them. I know Kaiser has had a big focus on health equity and cultural competency and, you know, they've done some studies showing that once they started to implement these programs, education focused on cultural competency, there was improvement in patient health. There was also a reduction in readmissions. So if someone is interested, they should kind of look at that Kaiser study. That's one organization that comes to mind for me. 

 

Zollicoffer: Kaiser is very strong. I would actually put Rush up in that top upper echelon as well. They move within a mission to eliminate human suffering. So I would advocate, you're right, Kaiser is going strong work Cristiana health system is doing well as well as Rush and when we think of some of the major barriers that hospitals face, especially in this political climate when it's easier to back down or stay silent, what do you think of when you put your compliance hat on when you put your legal hat on when you're looking at managing MCOs and ACOs, what are some of the major areas that hospitals face when they're trying to implement some health equity initiatives?

 

Howard: There are a number of them, one is just, some of it is just resistance, you know, you have your health care practitioners that don't want to go through the education, there hasn't been enough discussion around the need for it. So there's some resistance there. It also requires infrastructure changes that come with costs. So there are those costs considerations. There is a need to also just do assessments, look at policies and procedures and redo policies and procedures, implement new policies and procedures and in order to do that. And then there is, when I put on that that legal and compliance hat and as I said, I have the benefit of being on both sides, to have to discussion around patient-centered care and being on that side of being with family members who were the patients and understanding the importance of patient-centered care, but I've also been on the side of working for these health systems having to navigate a very complex regulatory environment. And so there has to be a balance when putting in place health equity programs making sure that you're not violating any regulatory or laws. For instance, the anti-kickback statute giving anything of value in order to influence a patient to use services that are going to be reimbursed by Medicaid or Medicare. And so if a hospital says, okay, or practitioners say, okay, I want to give patients incentives, even health plan incentives to do certain things. They have to be able to do that in a way where it's not viewed as a violation of the anti-kickback statute.

 

You have HIPAA considerations if they want to share data with partners, they have to do that in a HIPAA-compliant manner. It may be, you know, sharing aggregate data where you know, the information is de-identified. It may mean getting permission from the patients to share that data. It may mean putting business associate agreements in place making sure that the individuals that they're sharing data with can protect that data so all of those things. When you start to think about implementing programs, I always advise, you know, I always advise organizations that compliance should be involved in that process and sometimes it's necessary to bring legal involved. But, you know initiatives need to be looked at from a compliance perspective, it doesn't mean that they can't be done. It just means that they need to be done in a compliant fashion and that needs to come into consideration as well.

 

Zollicoffer: As a fellow DEI practitioner, I would add to those barriers the lack of education and consistency, right? So when you're thinking of executive teams and you've come into, you put on your DEI hat, taking off your compliance, have you experienced the lack of education and understanding of what health equity is? Many folks when they think about health equity, their filters are Black and Brown folks, right? 

 

Howard: Absolutely, you know as a consultant I go into a lot of organizations, sometimes they're long-term engagements like an internal chief compliance officer where I may be in there nine months one year, sometimes they're shorter and engagements, but I did have one client where there was discussion around health equity and it was a lot of resistance and the conversation was, do we have to do it? Is there a regulatory requirement? And then this discussion around health equity just spent off into a whole nother discussion around other DEI issues like hiring and procurement and then they wanted to set up a whole committee to address that so, you know, it spent off and it took on a whole life of its own that really moved it away from the health equity discussion. 

 

And at the time that I left the organization, I was working with them in a compliance capacity. They were very slow moving to put any kind of initiatives in place related to relationship to health equity because it just took on its own life and then they started thinking about you know from an operational standpoint. How much is it going to cost us to operationalize this because, you know, sometimes when you're on the perspective of wanting to do the right thing, you can think about all the things that need to be done, but not looking at what does it take from an operational standpoint? Like just collecting data, what changes have to be made in the system? You know, what things have to happen in Epic, which is what a lot of health systems use then what kind of training has to take place in order for people to understand what they need to do? Then you get the resistance because now you've added another step and from those who are entering data, providers, you have to fill out medical records. They start to balk at, wait a minute that you've added another step. We're trying to you know, we're trying to have efficiency here you're adding things. And so the discussion is, you know, do we need it? Do we need to do this? Do we have to do this? Because let me tell you what, you know, this is a heavy lift for us to make this change for us to start even collecting this data. So yeah, those are you know, those are real barriers and I've been in those discussions with organizations when they started to set when they considered, you know, whether we should do this and costs becomes a real becomes a real factor and also the education of you know, the need for the need for it from a community standpoint and also the need understanding that this is where we're going. This is going to start to be more of a focus from CMS for Joint Commission, for different accreditations, the OIG is going to start to focus on it more. So them understanding that they need to get ahead of it because this is where it's going and I don't think we're going to stop this trend.

 

Zollicoffer: I agree with you and even on the payor side, they're telling us that these changes are on deck. So there are incentives that are tied to financial incentives. There's a lot of reasons why this work is supposed to be done. I always think that you know, there's education to dismantle some of the thought processes and stereotypes for whom health equity benefits. There's a lot of filters folks go through but there's a lot of small steps that need to lead to building an infrastructure towards big change and a lot of this is about culture change, when we're looking, you know, from moving on the DEI maturity scale from being a check the box performative organization to being someone who embeds or a health system that embeds in the policies and work to then have transformation. Talk to me about how you've impacted complete culture change within a health care system so that health equity is front and center and everything that they do?

 

Howard: Well, a lot of it as you said is around education and I think that that education starts with leadership because it needs to be incorporated into mission statements and also needs to be incorporated into budgets. You know, I tend to be very direct in my speaking. So a lot of times that you know, the question is have you put your money where your mouth is? Yeah, that's a nice public statement you made but how is that reflected in the budget, because you have to allocate resources. And when people start seeing resources being allocated towards things and they started to start to take it more seriously, And also having someone who has responsibility, you know, where the bucks stops, that there are somebody who is taking ownership of health equity and that that person is at a high enough level in the organization that they can actually impact change. When you have your Health Equity officer five levels down they're not going to impact change the same way. So I you know, I talk to organizations about, you know, being able to put this into the mission and the plan and the budget and then to start to look at how you can begin to incorporate education through throughout the throughout the organization and being able to give real stories because I think the real stories are important. When people are just when people are just looking at data., it's a little bit different than when they when they are really seeing how they work in impacts individuals families communities and society.

 

Zollicoffer: You are so right and when you think about budgets, most folks think about budget in only like FTEs or labor, right? Do you have a DEI team? Do you even have a chief Health Equity officer or are you asking folks to donate their time when they have a full-time capacity on one side, to take on, you know, a hobby in essence of health equity? Or do you have dedicated resources and those dedicated resources in the budget? You know, if they're not there, there's resources, there's research, there's clinical outcomes, there's interpreter Services. There's so many different places for health equity to reside and are you funding all of those so completely agree with you there, does take a lot of change that's we see a lot of folks who are looking to you know, secure funds and grants to support the work because a lot of times of money just isn't in the health system to be able to dedicate to move it forward. When you think about where have equity is going, where do you see the trends?

 

Howard: Um, I definitely you know, as I mentioned earlier, I see the trend that health systems are going to have to pay attention and I think that they will pay attention because there are going to be regulatory requirements and it's going to be too costly not to pay attention. And you know when you start when you start tying care that is not delivered in a culturally competent fashion to quality, and quality being tied to false claims act, because when you're billing for a service that you really haven't delivered,  and if you haven't delivered it in a culturally competent fashion, then you haven't delivered it. When you have patients that come in and they are not adhering to a treatment plan or you're giving them a treatment plan that they don't understand like when you start getting into that health literacy, so a treatment plan that is misunderstood can be worse than no treatment plan at all.

 

And so, you know, I think the government is really starting to look at the impact of this and saying, what are we paying for? We're paying organizations to deliver competent care and if they are not, if they are turning a blind eye to it, then it's not, you know, it's not competent. So I look at it from that perspective from the legal perspective from the compliance perspective. And I think that that is going to really have an impact and I also think that outside organizations, community organizations play a really big role and or that health systems can start to partner with those organizations the better, it will be, and I do think that you're starting to see organizations partner with you know, health systems partner with community organizations in order to in order to have an impact.

 

Zollicoffer: I agree you see that more and more in today and it's very much needed to really touch all parts of the community, different touch points. There are some benefits to FQHCs, there's some benefits to clinics, small clinics as well as Health Systems to be a partnership. I'm going to wrap up with one last question because our listeners represent all levels of healthcare professionals, policy makers, folks who are part of associations, but if you could give one piece of advice to a healthcare profession or who says, wow health equity just feels like this mountain that I can't scale. What would be one thing that they can do to start addressing health equity within their organizations?

 

Howard: Well one of the things is that I think people need to understand where they are. And so being able to look at, you know, being able to look at their patient populations and then looking at their provider composition and saying, you know, is there a match here? And oftentimes you're not, you know, I mentioned that I worked on the payor side and on the outside you develop provider networks. And one of the requirements like when you're working for government program is that you have an adequate provider network and adequate is usually looked at as geographic. Like do you have enough providers within certain mileage to serve the population, you know a step further and say what's the composition of that provider network and does that provide a network reflect the population that you serve? So I think that one is just kind of taking an assessment of where you are from an individual standpoint. I think individuals can began to educate themselves. You know, there are a lot of courses that individuals can take at an individual level and then all so start to get involved in advocacy work, you know looking at organizations that they may be can partner with in order to advocate for certain things and you know, so from an individual perspective it's yes, it can be big, but you know, you take a first step and say okay. I'm going to start with me and say okay. What is it that I can do to expand to expand my knowledge base and who cannot partner with in order to be able to get better outcomes?

 

Zollicoffer: Thank you. Those are all fantastic insights for folks to start their work today. I'd like to thank you, Linda Howard, for sharing these incredible insights today to round out our podcast series on the role of hospitals and health systems and addressing health disparities. Linda, thanks so much for being with us. That brings us to the end of another episode of the Health Disparities podcast from Movement is Life. Once again, we'd love to see you Linda in person and our listeners and viewers at our upcoming annual summit. Registration is open. We will be in Atlanta Georgia from November 14th through the 15th at the Whitley hotel in the Buckhead area of Atlanta, Georgia. Please go to our website to find more information and to register: movement is life community dot org. I'm Christin Zollicoffer. Until next time, be safe and be well. Thank you Linda. 

 

Howard: Thank you.

 

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