The term ‘’health equity,’’ can oftentimes be interpreted as a synonym for ‘’equality,’’ meaning to achieve the same health outcomes for everyone.

Health equity has a broader meaning for Priscilla Wang, MD, MPH, Associate Medical Director for Primary Care Equity at Mass General Brigham and a primary care physician at Massachusetts General Hospital.

Wang believes that achieving health equity requires medical practitioners, investigators and healthcare system leaders to ask themselves tough questions about processes, diversity and disparities in care:

● Are we providing quality care to every single person regardless of their background, race or ethnicity?

● Does each patient have the same opportunity to achieve well-being?

● Are there language barriers that prevent patients from understanding the care they are receiving?

● What groups are disproportionally disadvantaged in the healthcare system due to structural racism and implicit bias?

According to Wang, questions such as these are pivotal to understanding the concept of health equity and building health systems that not only measure health disparities but actively develop processes to bridge the gaps in care that create health inequities.

Could Programs Designed to Address Disparities Also Be Creating New Disparities?

Wang and her research team studied the Mass General Brigham Integrated Care Management Program (iCMP) created about a decade ago to support vulnerable patients with complex health needs.

The iCMP operates via primary care-embedded interdisciplinary teams that work with patients and their providers to create and execute personal care plans to address barriers to care (i.e., limited appointment availability, geographic issues, transportation barriers, limited knowledge about care sites, etc.).

In her recently published study, Wang and her team studied whether race, ethnicity and language are associated with patient entry and service intensity within an extensive care management program, all from a structural health equity point of view. 

With the primary focus on coordinating care for high-risk and high-complexity patients, care management programs are becoming increasingly common in the United States as health systems, insurance plans and start-ups seek to improve patient care quality and efficiency.

‘’Care management is one of the cornerstone strategies in which any health system engaging in value-based care will participate. However, it is fraught with a lot of potential for bias’’ says Wang.

Looking specifically at iCMP, the research team took a closer look at three milestones on the patient journey in care management: patient selection, enrollment and engagement – looking for associations between these and race, ethnicity and language.

The research team sought to discover if patients of color or those with a preferred language other than English had a lower quality experience than their white or English-speaking counterparts.

A Different Experience in Care Management for Some Patients

The team looked at the patient journeys of 23,000 patients who were identified by a risk-based algorithm as candidates for the iCMP program between 2015 and 2018. 

They found that even after adjusting for medical and social risk factors, Asian patients had 26% lower odds, and Spanish-speaking patients had 21% lower odds of being selected by physicians as appropriate for the program than White and English-speaking counterparts.

Among those selected and enrolled in the program, Asian patients had 50% lower odds, and Hispanic/Latino patients had 31% lower odds of having a care plan created. Overall, patients who had a preferred language other than English or Spanish had 38% lower odds of having a care plan created.

Finally, the team found that patients with a preferred language other than English or Spanish had 13% lower odds of having as many encounters with their care team as their English-speaking counterparts.

Re-envisioning Care Management Through an Equity Lens: A Commitment to Providing Better Care

Beyond care management, Wang believes the study demonstrates the importance of not just measuring health equity by asking what the end outcomes of a program are – but by systematically evaluating for disparities in program processes. This will provide health systems with more concrete, actionable ways to address structural racism.

“I think this underscores that we need multiple ways by which patients can be identified and referred into programs. There are pros and cons to using an algorithm,” she says.

“Algorithms can be biased, and our system’s research has shown that. But this analysis also shows that relying on staff-based referrals could still introduce bias differently.”

Improving the patient’s journey: The second issue the study raises is the need to improve the patient’s experience through the system. “I think one efficient consideration that comes to mind is that we know patients with limited English proficiency are more likely to have lower-quality outcomes, so how do we work to address that?” says Wang.

Hiring culturally diverse staff: Under the leadership of study co-author and MGB care management program director Maryann Vienneau and Amy Flaster, MD, MBA, the care management medical director at the time of the initial study, the iCMP program made a commitment to translate all care management materials into top 10 languages spoken by patients in the system to increase translation support.

“Another piece that we feel is critically important and which we’re starting to do is to hire more culturally diverse care management staff to support our very diverse patients,“ says Vienneau.

Unanswered Questions and Next Steps

Many questions remain unanswered, Wang says. A crucial next step is to understand the perspectives of both staff and patients regarding their experiences in care management.

Wang plans to continue her vital work to identify how health inequities are perpetuated in our health system structurally – via policies, processes, algorithms, and other mechanisms beyond just interpersonal interactions.

She hopes to eventually see the mapping and evaluation of key processes through a health equity lens for other care management and patient-facing programs across the MGB system.

“If we say we’re trying to support our most vulnerable patients, to truly and concretely do this, we need to recognize how structural racism and implicit bias can play a role in each step of a program,” she says.

“Are we providing every person who enters our health system the same opportunity to achieve full well-being?”

About the Mass General Research Institute
Research at Massachusetts General Hospital is interwoven through more than 30 different departments, centers and institutes. Our research includes fundamental, lab-based science; clinical trials to test new drugs, devices and diagnostic tools; and community and population-based research to improve health outcomes across populations and eliminate disparities in care.
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