Addressing Family Medicine’s Capacity to Improve Health Equity Through Collaboration, Accountability and Coalition-Building

In 2016, Sandy Buchman, MD, et al defined social accountability as “the social contract that medicine has with society.”1 Indeed, social accountability is the beating heart of the medical profession. And yet, pervasive disparities in health and life expectancy persist, arising from inequitable access to wealth and education, and historical constructs such as racism and sexism that remain deeply entrenched in every aspect of our society.2-4 The medical system is no exception. “For care to be socially accountable,” Buchman et al continue:

…it must be equitably accessible to everyone and responsive to patient, community, and population health needs. It demands advocacy on the part of physicians to speak out on behalf of marginalized populations about the social conditions that contribute to disease, suffering, and death. It requires collaboration with partners and policy makers to create a truly accountable health care system. It supports primary care research that is responsive to perceived needs and translates into evidence-based practice and high-quality care. It necessitates medical education and training that models and teaches advocacy, community responsiveness, and health care provision that addresses the priority health concerns of the population served.1

Family medicine has long valued an ecological perspective of health, partnering with families and communities through approaches such as community-oriented primary care (COPC).5 Nonetheless, the quantity and degree of ongoing health disparities necessitates that family physicians specifically and intentionally attend to equitable outcomes for all.6 In recognition of this need, Family Medicine for America’s Health (FMAHealth) formed a Health Equity Tactic Team (HETT). Its charge: address primary care’s capacity to reduce health disparities and increase the social accountability of primary care organizations across the US. In order to move toward a socially accountable framework, the HETT believes the following strategies are necessary steps: establishm a shared language and learning framework, develop multisector partnerships, and transform leadership. Since its creation in 2016, HETT has produced enduring material and launched innovative projects. Now it is time to promote similar endeavors across the family medicine community and beyond. What follows is a summary of the outputs of the HETT, followed by recommendations for their use.

The HETT, in collaboration with Oregon Health Sciences University (OHSU) and OCHIN (a nonprofit health care innovation center based in Oregon), led planning and execution of the second Starfield Summit in April of 2017. Named in honor of pediatrician, researcher, and primary care advocate Barbara Starfield, MD, the Starfield II Health Equity Summit hosted a multisector audience from nearly 50 organizations, including medical students and family medicine residents.. The focus of the conference was “Primary Care’s Role in Achieving Health Equity.”7 For 3 days, a multidisciplinary roster of thought leaders shared their work through TED-talk-style “Ignite” sessions on four major themes related to health equity: social determinants of health; vulnerable populations; economics and policy; and social accountability. Following each talk, attendees participated in small group sessions facilitated by the Ignite speakers. Discussions were captured and summarized by note takers and shared with the larger group, who then proposed actionable interventions for the issues discussed. These proposed interventions formed the foundation of subsequent work by the HETT.

Health Equity Curricular Toolkit. Structures that perpetuate health disparities, such as sexism, racism, and inequitable distribution of power pervade all professions, medicine included. Meaningful change cannot occur without an explicit understanding of existing injustices. Despite decades of calls for medical education to provide training on fundamental topics of diversity, equity, and inclusion, and of addressing social determinants of health,8 few graduate medical education organizations are ready to meet the requirements of the Clinical Learning Environment Review’s Pathways to Excellence. They also cannot meet the Accreditation Council for Graduate Medical Education’s common program requirements to involve residents in the use of data and quality improvement to improve care systems, reduce disparities in health care and improve patient outcomes through experiential learning.9 The Liaison Committee on Undergraduate Education (LCME) requires instruction on cultural competence and health care disparities in their standards of accreditation. It is time for academic medical centers to start graduating true “upstreamists”10,11 in the delivery of health care; implementing curricula that help learners understand and identify systemic inequities and provide tools for engaging with community partners to promote meaningful change.

In response to this call, the HETT created the Health Equity Curricular Toolkit, which includes a guidebook and 14 modules addressing a range of topics, all inspired by Starfield II Ignite sessions. Curricular components are intended for a broad interprofessional audience, targeting clinical primary care and public health learners and faculty. Definitions and annotated bibliographies are incorporated through socioecological framing and the use of an equity lens (https://multco.us/file/8323/download) to promote development of common language and shared concepts. Understanding that some of the material (eg, topics of structural oppression) may challenge participants, the toolkit is accompanied by two supplementary podcasts, including one on facilitating conversations about inequity, oppression, and privilege. Proposed questions for group discussion and a wealth of resources are provided for each module, and they are intended to stimulate shared discourse of each participating discussant group. We anticipate that answers, ideas, and new questions will arise, enlightening and inspiring learners and facilitators alike. Our hope is that these outcomes will stimulate ongoing discussion and lead to positive changes within participating organizations. The toolkit is currently under evaluation by American Academy of Family Physicians’ (AAFP) National Research Network, and it will be made available in 2019.

A Business Case for Health Equity. Meaningful reductions in social disparities that underlie health inequities in our society will require building consensus among diverse partners outside as well as inside the health care sector. By one estimate, health inequity costs the US health care system $350 billion per year.12 As the economic drivers of communities all across the country, small- and medium-sized businesses bear a significant portion of the costs of health inequity. Absenteeism, decreased productivity, and rising insurance premiums are just a few of the expenditures borne by employers.13 At the same time, these businesses are inextricably linked to the communities they serve. If a community is unhealthy, the businesses cannot thrive. Employers recognize the business costs associated with employee health, but too often they do not recognize the role that they can play in the wellness of their communities. Understanding the importance of engaging the private sector to achieve health equity, the HETT focused efforts and resources on demonstrating an economic argument for health equity.

For that reason, the HETT is building a Business Case for Health Equity. Our work engages the private sector in addressing the needs of employees and their communities by demonstrating the potential return on investment for businesses that engage in these efforts. The first aim is to evaluate the experiences of businesses currently engaged with projects intended to improve health equity. We have completed six semistructured interviews with companies representing five distinct industries, six different geographic regions, and with a broad range of sizes. The second aim is to summarize existing research demonstrating the impact of health equity on metrics that matter to businesses. We have reviewed more than 45 articles to date. Data from aims one and two will be combined to create a series of executive summaries that can be used to guide small- and medium-sized business owners interested in improving employee and community health. One potential function of these summaries is to engage employees and community members in a collective impact model to design, implement, and evaluate interventions that improve health equity while providing a return on investment for the businesses. Another function is to create a toolkit that family physicians can present to local businesses (including hospital administrators) to help increase private sector involvement in improving local health equity.

Contemporaneous with the formation of the HETT was the launch of the AAFP Center for Diversity and Health Equity (CDHE). Prompted in part by a resolution passed at the AAFP 2016 Congress of Delegates, the CDHE was created to “create a culture of health equity” through workforce development, multisector collaboration, research and advocacy.14 The creation of the CDHE reaffirmed the AAFP Board of Directors’ commitment to assuming a leadership role in addressing adverse social determinants of health and support health equity.

The HETT and CDHE have developed a synergistic relationship, collaborating on numerous efforts that have been presented at meetings organized by the American Academy of Family Physicians, Society of Teachers of Family Medicine, American College of Osteopathic Family Physicians, Association of Family Medicine Residency Directors, and World Organization of Family Doctors. The aim of these presentations is to increase awareness of health equity among leading family medicine organizations, their members, and diplomats. In addition to collaborative projects, the HETT and CDHE provide mutual support for innovations (eg, CDHE’s The Everyone Project)15 and promote one another’s efforts through a robust social media presence (#FMHealthequity). In September 2018, the CDHE launched a new Health Equity Fellowship with the goals to create health equity leaders capable of communicating the effects of social determinants on health and their root causes. Fellows will work within the specialty of family medicine to advance health equity by translating the concepts of health equity into clinical practice, and demonstrating the ability to identify and act on a health equity issues that arise within the fellow’s organization, state chapter, and community. The first class of fellows will graduate in 2019.16

Coalition building with strong community partners will be essential to moving to socially accountable health care systems. The Starfield Summit brought forward successful examples going on across the country, and these are available in the Starfield Summit website. We also partnered with the Practical Playbook, a national program that supports multisector partnerships for health (www.practicalplaybook.org), and we became members of its National Advisory Council, linking family medicine with population health improvement efforts in cities, counties, and states across the United States.

Social accountability fundamentally requires that systems and their leadership to embrace its construct and take responsibility for its demanded equitable outcomes. The HETT has engaged leadership in all eight major family medicine organizations in the United States to participate in its activities. As discussed, workshops and presentations on topics of health equity have been deployed at conferences and leadership meetings of nearly every national family medicine organization. Without exception, presentations have been well received and have resulted in an increased commitment by individual organizations to increase efforts at promoting health equity.

One strategy to ensure health equity will remain a top priority is to diversify the leadership. Diversification of leadership is far more effective in promoting diversity and inclusion in organizations than diversity training workshops.17 The STFM Foundation has launched a campaign to support underrepresented in medicine students, residents, and new faculty to enhance the pathway not only into family medicine but also into leadership positions in family medicine.

As with any attempt to engender systemic change, achieving the charge set for the HETT has not been without challenges. Perhaps most significant is the recognition that moving the needle on health equity requires a significant amount of time and dedication. The HETT is a volunteer workforce. Notable accomplishments are driven by the collective passion of its members, not by financial incentive, and time is often limited by work responsibilities. Scaling of this foundational work will require a more significant investment of resources. We recommend the creation of at least one funded position within each of the national family medicine organizations dedicated to scaling the initial efforts of the HETT, developing organization-specific strategies for promoting equity and collaborating on equity efforts among family medicine organizations, as well as with other partners.

Health equity work requires an acknowledgement of power and privilege, including within the organizations leading this work. The HETT struggled with issues of power and privilege, necessitating creation of ground rules for communication to facilitate equitable discussions among the members of the team (Table 1). Similarly, there was a sense of hypocrisy that FMAHealth was driving efforts for health equity while its board had no representation by people of color. We recommend organizations that engage in similar work employ these ground rules or use them as a guide to create their own internal policies for effective communication.

Organizations responding to adverse social determinants of health require considerable attention to forging and maintaining strategic partnerships with a range of different organizations that may have very different cultures and approaches. Despite a willingness to work together, some potential allies may not be prepared to address topics such as racism, sexism, and other harmful paradigms that create and perpetuate many disparities. Disqualifying a potential partner on this basis reduces the potential size and power of the nascent coalition and serves as a barrier to achieving the central goals of the movement. This example highlights the challenge presented when attempting to realize a singular goal with multiple stakeholders. In these instances, care must be taken to: (1) develop a common language (jargon specific to the multiple fields can be confusing); (2) agree on priorities; (3) learn the importance of one another’s perspectives; (4) agree on the importance of health care quality, research-driven solutions, cost and service delivery systems; and (5) address potential conflicts of interest and power imbalance that may undermine the ultimate mission of serving populations from a community-centric, evidence-based and equitable lens.18

Another challenge is faced specifically by large organizations serving primarily disadvantaged populations. Improving health equity requires attention to both horizontal equality (assuring that patients with equal needs receive equivalent, high-quality care) and vertical equity (providing additional care to those who need it most, while assuring that resources are sufficient to continue to care for all patient needs).19 Different players may value one aspect of equity over another, and this requires careful examination of how to assess progress, since different lenses (ethics, economics, and epidemiology) may lead to prioritizing one aspect of equity over another. Enhanced clinical protocols, for example, might improve the overall experience of care for all patients, but perhaps more so for those with fewer resource constraints, thereby decreasing absolute levels of inequity while increasing relative inequities among groups.

The first step on family medicine’s journey toward health equity is to conduct an honest assessment of systemic inequities within family medicine organizations. How are current practices contributing to disparities based on race, gender, geography, and other factors? What barriers to equity currently exist within our institutions? How can we improve the diversity of our membership, especially within organizational leadership? We recommend utilizing tools such as the equity lens and an agreed-upon set of ground rules for facilitating respectful communication.

Family medicine is well-positioned to educate students, residents, and faculty about racism and root causes of disease, and to create safe and courageous spaces for dialogue, commitment, and community activism. Our specialty is ubiquitous within medical programs across the country and should be a leader in evaluating social needs as integral to ensuring optimal health. The Health Equity Curricular Toolkit, developed by the HETT, is an optimal tool for engaging learners around topics of diversity, equity, and inclusion. We strongly encourage adoption of this toolkit by medical schools and residencies.

Finally, health equity cannot occur through unilateral change. Communities and multisector stakeholders must be involved for transformative efforts to be effective. Applying a Health Equity and Empowerment Lens20 can be transformational in improving health for all members of a population. The lens created by Sonali S. Balajee, MS, et al, from Multnomah County in Oregon, offers academic medical centers, health care organizations, clinicians, and health care systems an approach that informs the organizational mindset and capabilities needed to introduce changes in care that address the underlying reasons for disparities in patients’ experiences and outcomes. We encourage all nascent partnerships to consider these tools to inform their efforts. While addressing adverse SDH takes the whole village, uses of these lenses and frameworks can move primary care forward in policy, practice, and outcomes that begin to address the many adverse SDH affecting the health of populations.

On the horizon, we are hopeful that the work of the HETT can continue shaping transformative efforts at health equity. The Business Case for Health Equity is one such product that we feel has significant potential to increase participation in health equity projects. We are excited for the continuation of this and other work by the CDHE, and look forward to supporting the Health Equity Fellowship.

In closing, while we look at the future of family medicine, we need to continuously improve and analyze the present through a health equity and quality improvement lens. In doing so, family medicine will rise as the specialty that truly improves health in all communities.