Applying an Equity Lens to Changes Aimed at Improvement
The Annual Wellness Visit
In the United States, the Centers for Medicare and Medicaid Services (CMS) pays for an ‘Annual Wellness Visit’ that covers screening for Medicare beneficiaries, well-matched to age-friendly care recommendations. Annual Wellness Visits aim to identify health issues early and, with appropriate follow-up, can reduce illness burden to benefit patients, families, and society.
Annual Wellness Visits are an example of a health care innovation that is diffusing—becoming more commonly practiced—since CMS began paying for it in 2011. In 2015, more than 20% of primary care practices provided annual wellness visits to at least 25% of their eligible patients.
However, while diffusion of Annual Wellness Visits has potential benefits it also has the potential to widen health disparities—differences in health outcomes and experience between social groups. This downside is described in an article in this month’s Health Affairs that focuses on diffusion of innovations in health care (Ganguli et al. “Practices Caring For The Underserved Are Less Likely To Adopt Medicare’s Annual Wellness Visit”, Health Affairs, 37, 2 , February 2018, pp. 283-291).
As the authors note, “…[Annual Wellness] visit rates were lower among practices caring for underserved populations (for example, racial minorities and those dually enrolled in Medicaid), potentially worsening disparities.” (from the abstract).
Widening disparities based on social status or race means less health equity—a less just and fair health system, with less just and fair outcomes and experiences for groups of people.
The possibility that an innovation may harm health equity shouldn’t surprise us as “…resource-rich communities tend to adopt innovations early relative to poor communities.” (Dearing and Cox, “Diffusion Of Innovations Theory, Principles, And Practice” Health Affairs, 37, 2 , February 2018, p. 182).
Other factors like implicit or subtle biases on the part of innovators also contribute; for example, commercially released facial recognition software performs better for light-skinned males than other groups, as summarized in an MIT Media Lab study discussed here, accessed 12 February 2018.
An Equity Lens: Three Actions to Look at Performance and Changes
Work on the Pursuing Equity initiative with the Institute for Healthcare Improvement has taught me that viewing every health care system through an equity lens provides a practical path forward.
Here are three ways to start to apply the equity lens:
- Stratify dashboard performance measures by relevant social factors, typically race, ethnicity, preferred language, and payer. When you look at health outcomes of patients, experience of patients, and staff vitality, appropriately stratified, there will often be striking and persistent differences that demand inquiry and present opportunities for improvement.
- Require every improvement project to (a) stratify performance before and after improvement using relevant social factors and (b) test changes in ways that surface differential impacts for different social groups.
- In planning for innovations and new service designs, require design teams to (a) consider explicitly ways that the innovation or design might harm equity and (b) modify the innovation or design to prevent such unintended consequences.
These three actions make equity ‘standard work’ for a system’s executives and managers in the course of their regular work to analyze performance indicators and lead improvement and design projects.
Using the equity lens means equity work is integrated into the regular work of the organization and its people, not isolated in a staff department or relegated to special events.
