Moderator, Dr. Jain: We hear a great deal about the many disparities that exist in our society such as income or education. We want to talk about disparities in health, which are differences in mortality rates or disease burden such as breast cancer — and disparities in health care, which are differences in insurance rates, quality of care, and access to care. So, what are disparities and how should people think about disparities in health and health care?
Shantelle Leatherwood: So #1, disparity is a major difference between a specific or identified population. That could be demographic differences, socioeconomic differences, location differences. At Christ Community Health Services, we see all of these. We’re a federally qualified health center, so we’re required to look at the demographics of our defined population in specific zip codes across the city.
We also look at poverty and its effects on health care, access to health care, and if individuals delayed receiving care because of their socioeconomic status or even their education. There are also differences in health conditions, specifically related to chronic illnesses.
Dr. Michelle Martin: When I think about disparities, I think about differences. But we’ve also started to think about the word inequity, which adds the concept of injustice when thinking about disparities in health. That’s probably why we’re all around this table, because we know that things can be different and that we are in positions to make that difference. That’s why I came to Memphis — to contribute and be part of that great difference-making. When you think about inequities, you begin to think about social justice, the social determinants of health, and unfair differences.
Michelle Gilchrist: In addition to health care equality and disparity, there are barriers that prevent access that occur because of policies. It isn’t that policies are created without good intentions. It’s that policies — without the input of the right people — create unintended barriers that unfortunately affect certain demographics or health populations. So, the barriers often occur out of good intention.
Disparity is a barrier that is created because there’s not enough diversity around the table. When these policies become law —health care facilities, hospitals, insurance companies, and professionals — must comply with regulations that they’re not empowered to affect. Health care disparity boils down to barriers created by the people in power that affect people with no power.
Dr. Jain: I’m convinced disparities exist. In my field of infectious disease, we can look at HIV. HIV disease among whites is six per 100,000 and in blacks it’s 53 per 100,000. Death from HIV: three per 100,000 in whites, 23 per 100,000 in blacks. That’s an enormous difference. What examples and data can you share that show that disparities exist?
Dr. Mike Edgeworth: First, this brings up a great point of using data to validate that disparities exist. Second, we also need to use data to track and trend any intervention we have. If we agree that disparities exist, are we making an impact through our efforts and interventions?
An example we could use from Cigna data is breast cancer screening in African Americans versus white women. In 2012, Cigna conducted internal analyses and found significant racial disparities in screening rates between African-American and Caucasian Cigna customers in Tennessee.
According to the American Cancer Society, Caucasian women had a higher incidence of breast cancer until 2012, when we notice that the incidence of breast cancer in African Americans caught up to the rates for Caucasian women. In Tennessee, we actually see that the incidence of breast cancer is higher for African-American women than in Caucasian women.
However, our data showed that the screening rate for breast cancer was significantly higher for Caucasian women than for African-American women. So, you have this clear disparity — Caucasian women were more likely to have recommended breast cancer screenings than African-American women despite seeing that African-American women were at higher risk. And we all know that earlier detection can lead to better outcomes and improved survival.
Gilchrist: On a national scale, when we look at the numbers from the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Disease, we see that 650,000 people are suffering from end stage renal failure in the United States.
We look at who makes up the 650,000: 50% are minority; 50% are not minority. But when you look at how many people are actually placed on the transplant list, you have 650,000 in need of a transplant, but you only have 113,673 who are placed on the list to even receive an organ. Of that, 94,915 are waiting to receive a kidney.
In 2018, there were 36,527 transplants performed. Of those 36,527 transplants, Caucasians represented almost 60% of recipients who received a transplant, although minorities represent nearly 50% on the list. So, there’s a disparity when you’ve got only 21% African Americans and 10% HispanicS receiving a transplant. The real question is: What is preventing some people from getting on the list?
The barrier is unfortunately financially based. If a kidney is a $400,000+ transplant, and you need to pay $80,000, most minorities and low- to moderate-income families can’t afford that expenditure.
Dr. Martin: With breast cancer, the death rate for non-Hispanic black women is 41% higher than the rate for non-Hispanic white women. For uterine cancer, the number is even more startling. The death rate for non-Hispanic black women diagnosed with uterine cancer is 98% higher than the rate of their white counterparts.
Why these differences exist is complex. In the case of breast cancer, higher prevalence of obesity, advanced stage of cancer at diagnosis, breast cancer type, health care access, adherence to treatment, and more medical comorbidities are all thought to play a role. How each of these factors influence outcomes are research questions that can be answered. There are disparities all along the trajectory of cancer from cancer risk factors, detection, care and outcomes.
Leatherwood: Most definitely disparities exist, especially for individuals who are uninsured. We experience this on a daily basis because there are barriers to specialty care, surgeries, mammograms, and screenings. Additionally, there are financial and transportation barriers for those who are uninsured.
There’s a lack of specialists who will accept an individual who’s uninsured. As a result, individuals delay needed and recommended care because it’s not affordable. Some specialists in the area will not accept them and some hospitals will turn them away. So, what does an individual do? If you don’t have a health care organization like Christ Community or the National Foundation for Transplants to advocate for you or provide discounted care, then many of their chronic illnesses are unaddressed or worsen leading to devastating health outcomes.
I’ll share a story — a couple reached out to me about an uninsured relative. He had substance abuse issues and chronic pain but couldn’t determine the cause of it. He finally had a friend perform an MRI, which showed a ruptured disc. Of course, no one would care for him. So we scheduled an appointment for him into one of our clinics to see one of our providers. That was the first step. I also shared with them not to worry about fees.
From there, we referred him to one of our hospital partners, where he’d have the surgery he needed. I told them it was going to take some months — there are long delays for individuals who are uninsured. Sometimes specialists only have a designated number of appointment slots for uninsured individuals.
He eventually had the surgery and reached out to me to express his gratitude. There are so many others like this. He could have continued living in persistent pain, which would have worsened his addiction as well. At this time, he is recuperating and living pain-free because of our assistance.
Dr. Jain: We know disparities can be from individual behavior, provider’s practice, our cultural bias, the present health system, and the many social determinants of health. But why do disparities exist?
Dr. Martin: It’s hard to address just one area. I think it’s multifactorial, so the most effective strategies are going to touch many levels.
I conducted a research project some years ago with rural, primarily African-American adults with hypertension. We looked at medication adherence: 36% of participants indicated that they forget to take their blood pressure medicine which speaks to individual behaviors contributing to medication nonadherence; 34% indicated that it was hard to get to the clinic/drug store to fill their prescription, which speaks to access and transportation.
We also learned, that those who were less adherent with their medication were also more likely to indicate that they found health care appointments to be stressful and more likely to indicate that they were less likely to feel comfortable asking questions of their physicians.
So in this one study, we saw factors across multiple domains that were contributing to medication non-adherence. So when we seek to understand why health disparities exists, we need to use a broad lens when answering that question.
Leatherwood: I’d say that’s the same in an urban community. A couple of years ago, our organization conducted a research project called Orange Hype that used community health workers. The workers went door to door enrolling individuals into this trial.
We found the same issues — a lack of adherence to medications. One major reason stemmed from the affordability of the medications. Another stemmed from a lack of awareness regarding the availability of discounted medications within our neighborhood health center pharmacy in Orange Mound.
Another factor is poverty. It affects a number of areas. Consider this: for each individual in this Room, we are probably all insured. It is easy for us to call our physician to schedule an appointment and pay for our visit— even with a high deductible plan, you have an HRA for visits and medication.
Someone who’s uninsured and in poverty thinks: “I know I’m sick, but I can’t pay for a physician visit.” Typically, they’re asked to pay something upfront, and then there’s a lab bill later. From there, they wonder how they’re going to pay for medication.
We have witnessed individuals with hypertension, for example, split pills to make them last, and as a result, their hypertension spirals out of control.
Dr. Martin: Because we have talked about access and poverty, I’ll add that for many individuals who have limited financial means — even when they would like to attend a health care appointment — they often have to overcome many barriers to do so.
For example, individuals may need to start their day at 4:00 am, take multiple buses, all to keep a 9:00am medical appointment. Or they may have to depend on obtaining a ride from someone else and hope that the person providing a ride has a reliable vehicle. Or they may have a job that does not provide sick leave, so the decision to not attend work and keep a doctor’s appointment, also means that they will also miss that day’s income.
When it’s that challenging to keep a doctor’s appointment, it is understandable why someone may wait until they’re really sick before seeking care.
Dr. Edgeworth: A lot of those barriers exist for the insured as well as for the uninsured. I believe it’s important to understand what impacts health outcomes — ultimately, what impacts your health in the long run.
As a doctor, it’s a little humbling to look at the percent of the role that clinical care plays in your ultimate health outcome. According to a study in the New England Journal of Medicine, it’s 10%. I went to medical school believing that number was a lot higher. The same study showed that 60% of your health and well-being is attributable to social, economic, and healthy behaviors. It’s always helpful to be reminded of that. And those factors impact the insured, the uninsured, everyone.
Traditionally, the health care system doesn’t “treat” the socioeconomic factors that lead to poor health outcomes. We’ve historically focused on direct health care services like medications to treat hypertension, surgery to remove tumors, vaccinations to prevent infection, etc. — but we haven’t looked at what we can do for social determinants of health like food deserts, transportation difficulty or housing insecurity.
It’s exciting that we’re finally living in a time, I believe, where the health system — payers, providers, systems — are coming together with experts in this area. It’s not us in the health care world. It’s the community organizations and services provided by the likes of Christ Community and National Foundation for Transplants. The experts are those who live and work in these communities, and it’s the collaboration with these organizations that’s going to help drive better outcomes.
Gilchrist: All of us — hospitals, health care providers, doctors, physicians, insurance companies — want better patient outcomes. And I think patients want better health outcomes. We can all agree that the end objective is improved patient care and optimal health outcome. I think the barrier to much of this is the high cost of medication.
Additionally, we need to think about how best to educate low- to moderate-income families who have transportation or housing issues — about alternatives to receiving the medication that’s needed for them to achieve optimal healthcare treatment. Mail pharmacies, block chain pharmacies, and community programs are options if they can’t afford their medication. We need to educate this population about programs like Christ Community and how these programs function.
Without health care literacy and understanding of what questions to ask and how to access programs that can provide patients with affordable medications, then patients are less likely to take the medication that would lead to better outcomes.
When transplant patients, for example, fall into the donut hole, which is a little bit below $4,000 for Medicare, they have to pay for prescriptions out of pocket. Instead of seeking alternatives during the gap, they begin to cut back on frequency and volume in order for their immunosuppressants to last longer — not realizing the lower dosage and frequency impacts their outcome.
We can begin to make prescriptions affordable in the donut hole through programs like Good Shepherd, which essentially says: You still need to take the medication, so let’s make it affordable in the donut hole. And when the patient is out of the donut hole, Medicare picks back up and they’ll cover it 100%.
A lot of the medication issues are because transplant patients have to pay $3,000–$8,000 a month in medication costs, which they cannot afford on their own. That’s an income for most people. If we can’t make medication affordable at the point of unaffordability, then we’re not promoting increased patient outcomes.
Dr. Jain: How do we overcome inequality and reduce the disparity that exists in health care? What are some solutions at the national level?
Dr. Edgeworth: Medicare has traditionally only allowed Medicare Advantage plans to have basic and supplemental benefits that are clearly a direct health care service or directly tied to a health care need. And they’ve realized that there’s so many other factors that are impacting poor health outcomes, so Medicare has relaxed some of those restrictions.
We, as the health plans, are now able to offer supplemental benefits that are not traditionally health-related services but that do have an impact on health outcomes, such as food insecurity. Cigna-HealthSpring, for example, is providing post hospitalization meals for patients who have recently been in the hospital, because we know that patients who are recently discharged from the hospital and go home with food insecurity or live in a food desert are at a much higher rate of readmission to the hospital. Providing meals after discharge from the hospital helps reduce readmission rates, keeping the patient at home, where they would rather be.
Gilchrist: In the transplant community, the Affordable Care Act (ACA) has been great for our patients. One reason is because of the removal of the lifetime limit. The most expensive organ is a heart at $1.4 million. If the lifetime limit is $1 million, then with the old model, a lot of people weren’t even being listed because they didn’t have $400,000+. So with that removal, there’s more minorities and low- to moderate-income patients who are being placed on the transplant list and, therefore, as a result, receiving equal access.
The ACA also removed preexisting conditions. For example, if I receive a transplant and move to another insurance company, it’s not a factor. If someone who received a successful transplant finds themselves in need of another transplant 10 years later, they cannot be denied. So there are pros to very costly health care treatment through the ACA, which are beneficial to the transplant community.
Dr. Martin: One thing that’s been very important is the establishment of the National Institute on Minority Health and Health Disparities at the NIH. It’s dedicated to understanding and addressing health disparities and funding research to do so.
Leatherwood: We’re seeing a movement at the national level from Medicare and Medicaid around reimbursing for non-revenue generating services—such as social workers, food vouchers, gym memberships, and transportation.
Additionally — which may appear to be a conflict — however, the value-based health care movement with its focus on health care outcomes, has also brought to light this need to address social determinants to address barriers to improving one’s health.
As a federally qualified health center (FQHC), we’re seeing this shift also come from the Health Resources and Services Administration and the Bureau of Primary Health Care — they’re training and equipping all FQHCs in this area. For FQHCs, we’re considered the nation’s safety net. As a result, we’ve been addressing disparities related to social determinants nationally since the early ’70s.
Dr. Jain: How can we resolve disparities on the local level?
Leatherwood: Strengthening partnerships between organizations and providing wraparound services is key. In partnership with Baptist, we provide primary care services to the homeless population in Shelby County.
We’ve also entered into a partnership with Catholic Charities of West Tennessee, which is committed to providing social services to homeless individuals. We’ve established a freestanding homeless health center within Catholic Charities in Memphis. It places us in close proximity to their social services. We now have the ability to direct a patient downstairs or upstairs to discuss housing issues or to receive a voucher for food or clothing.
Dr. Edgeworth: I’ll circle back to the breast cancer screening example. Cigna took to a multifaceted approach to address the fact that African-American women were not having breast cancer screening at the rate of white women.
Over two years, we noted that a couple of initiatives made some impact, but we also realized that our customers living in Shelby County continued to lag behind. This is where partnership is essential as we address social determinants of health, certainly at a local level.
Cigna worked with Methodist Le Bonheur and the Congregational Health Network to embark on a targeted approach to women who had not had screening performed. In 2018, Cigna repeated the analysis and demonstrated that the breast cancer screening disparity between African-American and White customers — originally identified in 2012 data — had not only been eliminated, but screening rates for African-American women are now actually higher than those of White customers in both Shelby County and the state of Tennessee. This tremendous success could only be accomplished in collaboration with our community partners.
Dr. Martin: I’m very excited about The University of Tennessee Health Science Center’s (UTHSC) Quality Enhancement Plan that will enhance student learning as it relates to the social determinants of health. UTHSC’s faculty, staff, and students voted and selected this area of focus.
As we educate this next generation of health care professionals and implement the Quality Enhancement Plan, we have several student learning outcomes. These include students being able to describe how the social determinants of health contribute to health disparities and students being able to demonstrate integrating social determinants of health and cultural humility into their interactions with patients
Gilchrist: Good Shepherd Pharmacy, which is a local nonprofit community pharmacy, and the National Foundation for Transplant have engaged in a partnership to help low-income families in the state of Tennessee who are in need of a transplant or who need maintenance medication that contributes to their need for a transplant, to help them reduce their medication costs.
Plavix, for example, can cost $100 per month. Through this partnership, patients can get a 90-day supply for less than $10 bucks. Programs like that allow for better patient outcomes.
Additionally, they began a block chain pharmacy program in which they’re procuring medications that are primarily for cancer patients that are high-price meds, which low- and moderate-income families can benefit from by receiving those medications at a significantly reduced cost.
That’s a great step in the right direction to help with medication management, use and access to high-priced medication to promote better outcomes.
Moderator – Dr. Manoj Jain, MD MPH is a physician, a writer, and a national leader in healthcare quality improvement. Dr. Jain’s writings appear in the Commercial Appeal, Washington Post, and New York Times He received his engineering, doctorate, and public health degree from Boston University, Presently, Dr. Jain is adjunct assistant professor at Rollins School of Public Health at Emory University.
Panelist – Shantelle A. Leatherwood, MHA has served as the Chief Executive Officer for Christ Community Health Services since 2016. Prior to the appointment to the position of CEO, Ms. Leatherwood served as Christ Community Health Services’ Chief Administrative Officer. Mrs. Leatherwood holds a Bachelor’s in Health Administration and Planning from Tennessee State University and a Master’s in Health Administration from the University of Missouri-Columbia.
Panelist – Dr. Michelle Martin, PhD is a Professor of Preventive Medicine and Director of the Center for Innovation in Health Equity Research: A Community Cancer Alliance for Transformative Change at the University of Tennessee Health Science Center. She co-leads the Tennessee Clinical and Translational Science Institute (TN-CTSI) which addresses health inequities in the South.
Panelist – Michelle Gilchrist is the Chief Executive Officer for the National Foundation for Transplants (NFT).Prior to joining NFT in 2016, Michelle dedicated nearly 30 years to improving social conditions of diverse socio-economic classes. Her work has resulted in more than $250 million raised to combat societal inequities. She is currently pursuing a Doctor of Public Health degree which she plans to begin in fall 2019.
Panelist – Dr. Mike Edgeworth is a board-certified neurologist and Senior Medical Director at Cigna-HealthSpring. His work focuses on value-based physician partnerships, population health management and chronic disease program development. Dr. Edgeworth has helped launch, manage and grow several initiatives at Cigna-HealthSpring, including programs focused on palliative care, COPD, heart failure and behavioral health.