To Achieve Health Equity, Make Quality Our North Star

Mark D. Smith, MD, MBA, Clinical Professor of Medicine, UCSF; Founding President, California Health Care Foundation

Social conditions affect physical health—and this should not be news. Way back in the nineteenth century, Rudolf Virchow examined typhus epidemics through this lens. In more recent decades, the famed Whitehall studies in Britain have shown associations between socioeconomic status and mortality. Yet although the connections between living environments and health are not news, they don’t appear in our news coverage as often as they should.

In the early days of the pandemic, media coverage observed that Black and Brown people were getting sicker, were likelier to be hospitalized, and more often died of COVID-19. The explanation offered was that they had preexisting conditions—but this description ignored social conditions. Often, greater risk of mortality from COVID-19 connected to who was driving the bus or train, who lived in a multigenerational household, or who was working shoulder to shoulder in a manufacturing plant.

These occupational, generational, and locational factors illustrate the broad tapestry of distinctions and discrepancies in American life that made some people more vulnerable to the pandemic than others. Which means we must ask: Why did these groups have more preexisting conditions in the first place? The pandemic highlighted preexisting inequities.

Fortunately, awareness of the social determinants of health (SDOH) was growing even before the pandemic—from 2015 to 2019, there were more articles citing SDOH than in the previous 30 years. Our profession had been primed with the knowledge that patients’ health sometimes is grounded less in access to medical care and more in broader issues of where they live, how they grew up, what services—transportation, food, and others—are available in their community. SDOH, which can contribute to health disparities, are finally a focus and priority for many healthcare institutions and organizations.

Choose Any Quality Measure, Examine for Equity, and Begin

The Institute of Medicine (IOM), now the National Academy of Medicine (NAM), defined quality in healthcare with six domains: (1) safe, (2) effective, (3) efficient, (4) timely, (5) patient-centered, and (6) equitable. We have a professional responsibility—and should have a commitment—to providing high-quality care to all patients. Looking at that sixth domain, equitable, means being aware of characteristics and factors that could make patients less likely to receive quality care. These include gender, race or ethnicity, religion or visible marks of religion, sexual orientation, certainly location—people who live in some areas are living in care deserts. Crucially, our commitment to the provision of equitable care should not vary according to patients’ political or social views and whether they agree with us.

To meet our commitment to providing the same quality of care to everyone, any medical professional can start with their own most important quality measures. These will depend upon their specialty or role. For example, an orthopedic surgeon might measure revision rates or infection rates. An administrator, readmission rates. The CFO might analyze debt collection aggressiveness. A hospitalist might look at pain control. Wherever and whoever you are, start with whatever your important quality measure is. Analyze it by race, by gender, by principal language, by ZIP code. Analyze your quality measure by the dimensions that we know have inequities, and you will find work to do.

Telehealth Improves Access to Care—for Some Patients

The pandemic introduced millions of Americans and hundreds of thousands of healthcare providers to virtual care. Now, people wonder whether they really need to travel across town and back for a 10-minute interaction. There will always be a need for in-person interactions, but medical professionals recognize the potential in providing certain kinds of care more quickly and more cost-effectively.

To that end, almost all practices need four channels: (1) in-person interactions in a brick-and-mortar space, (2) video visits, (3) asynchronous communication via text and/or email, and (4) phone—don’t forget the phone. There are a lot of people who either don’t have broadband or don’t want their doctors looking over their shoulder at their house because they’ve got five kids and only one place where the computer is.

Telehealth can simultaneously reduce and increase barriers to care for minorities, seniors, and patients in rural areas. On the one hand, it eliminates the need for transportation, childcare arrangements, or time off work. Therefore, it is a positive overall that the Telehealth Expansion Act of 2023 makes permanent certain regulatory flexibilities that were offered early in the COVID-19 pandemic. On the other hand, telehealth is not a cure-all when it comes to access to care, because the expectation that a patient can access a remote visit can be a barrier to those who need access to a computer or broadband.

Whether it’s wound management or blood pressure assessment, the technology to provide care remotely at least some of the time now exists. The question is less about whether we can provide the care remotely, and more about how we can set up a payment environment and operational efficiencies to take advantage of these technologies. Not to mention whether our patients are equipped to take advantage of these technologies. Practices and institutions will need to take their patient populations into account as they consider best practices for their four channels for patient interactions.

Making Quality Our North Star 

The issue of equity is complex for many people, because it raises other complicated questions about political and racial identities and the country's history. People can get stuck in ways they should not, and this can tear organizations apart internally.

Nevertheless, equity is an irrevocable part of quality. It must be treated as such in order for us to meet our primary professional responsibility, as individuals and organizations, of providing care. If we start with the quality measures that are most important to our institutions, specialties, and practice partners, and if we examine them in a clear-eyed fashion to see whether everybody gets the same outcomes, whether everybody is getting the same quality care, we will see more than enough to go to work on. If we keep quality as our North Star, we can follow it toward creating the kind of equitable environment in which we’d like to work.

Mark D. Smith, MD, MBA, is currently Clinical Professor of Medicine at the University of California, San Francisco. From 2015 to 2019, he served as Co-Chair of the Guiding Committee of the Health Care Payment Learning and Action Network. Previously, Dr. Smith was the founding President and former Chief Executive Officer of the California Health Care Foundation, from 1996 to 2013. He was elected to the National Academy of Medicine in 2001 and chaired its Committee on the Learning Healthcare System, which produced the widely publicized 2012 report Best Care at Lower Cost. Dr. Smith serves as a Director of Teladoc Health, Inc., Phreesia, the Commonwealth Fund, and Jazz Pharmaceuticals. He earned his bachelor of arts (BA) degree in Afro-American studies from Harvard College, his doctor of medicine (MD) degree from University of North Carolina at Chapel Hill, and his master of business administration (MBA) degree in Healthcare Administration from the University of Pennsylvania. He maintains a clinical practice in HIV at the Positive Health Practice at Zuckerberg San Francisco General Hospital.

Dr. Smith spoke at the 2023 gathering of the TDC Group Executive Advisory Board Meeting in Napa, CA, which brings together top healthcare executives, academic researchers, and clinical leaders to discuss the changing landscape of healthcare as part of the Leading Voices in Healthcare initiative.