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Trust in Health Care
June 7, 2019

Building Trust in Health Systems to Eliminate Health Disparities

Author Affiliations
  • 1Department of Internal Medicine, Texas A&M Health College of Medicine, Dallas
  • 2Baylor Scott & White Health and Wellness Center, Dallas, Texas
  • 3Department of Internal Medicine, University of California, San Francisco
  • 4Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 5Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA. Published online June 7, 2019. doi:10.1001/jama.2019.1924

Health systems play a vital role in enhancing the health of the communities they serve, including historically underserved populations with disparate health outcomes. Eliminating health disparities is a critical aspect of enhancing population health that requires collaborative input from multiple entities including health systems, government agencies, community organizations, and residents. A lack of clarity among contributing entities about the roles and responsibilities of health systems in addressing root causes of health disparities make the challenging goal of eliminating them even more so. This raises questions in communities served about the extent to which health systems are truly committed to advancing health. The resulting tension compounds the historic lack of trust between health systems and underserved communities and undermines collaborative work toward mutually beneficial outcomes of improved health. Health system leaders need to lead in addressing this tension by building and sustaining trust with and for their communities.

Opportunities to Resolve the Tension
Develop a Common Understanding of “Disparities”

Underserved communities see and have devastating effects of disproportionately poor health outcomes that compromise quality of life and financial productivity. Because communities support health system finances through third-party payment, tax incentives associated with nonprofit status, and personal participation in their research and education missions, they reasonably believe that health systems can and should address the myriad causes of poor health outcomes to achieve health equity. Many health system leaders similarly recognize the complex causes of health disparities but view their role in eliminating them as confined to equitable provision of health care across populations they serve.

A focus on health care delivery as the primary way by which health systems contribute to eliminating health disparities has limitations. First, it focuses only on individuals already engaged with the health system. Historically underserved populations continue to have limited access to primary care and a greater reliance on expensive and fragmented health care services.1 Second, this focus is reactive and so misses opportunities to prevent adverse health outcomes rather than treat them once they have arisen. Third, it is costly. Consequently, strategies that focus on health care delivery have not been successful in enhancing population health.2 Reliance on strategies that optimize the process of health care delivery but do not improve population health outcomes may be viewed by the community as evidence that commitments of health system leaders to improving health are shortsighted or disingenuous.

Achieving equitable outcomes requires eliminating health disparities and obligates that health systems move beyond their traditional roles of simply providing high-quality health care to promoting equitable health and health outcomes. Committing to a shared vision of elimination of health disparities provides health system leaders with opportunities to work collaboratively with non–health system partners to leverage resources addressing health-related social needs, such as nutrition, housing, and transportation, toward improved health outcomes for all populations and even greater improvements for disadvantaged groups. Because many needed non–health system resources are in communities that are served by health systems, this provides the opportunity for health system/community partnerships.

Align Purposes for Eliminating Health Disparities

While there is a clear moral argument for eliminating health disparities, health system leaders face the more immediate challenge of maintaining the economic health of their systems and so might see little incentive to partner with non–health care entities to help eliminate health disparities. The transition from our current fee-for-service reimbursement system to value-based care (VBC)3 offers opportunities for health systems and communities to align purposes for eliminating health disparities. A VBC system rewards the good health outcomes sought by communities. Exposures to negative social determinants of health disproportionately cause poor health outcomes for underserved populations.4 Such a reimbursement environment will incentivize health systems to mitigate these factors, in contrast to the traditional health care delivery model that does not routinely address health-related social needs.5 To address social determinants of health and achieve VBC through eliminating health disparities, health systems must reach beyond boundaries of clinical care to communities they serve.6 The evolving focus on VBC incentives provides a common vision, and shared mental model, around which health systems and communities can align to eliminate health disparities.

Health system leaders have the opportunity to lead in establishing a shared mental model of the specific disparities to be eliminated, and the rationale for doing so, that enables aligning purposes for eliminating health disparities. In doing so, they will help their collaborators see that although health systems play an important role, their work alone is not sufficient to achieve good health outcomes for all populations. This proactive effort will help set the stage for gaining the necessary trust for achieving this goal, particularly among underserved communities. System leaders must then work in partnerships to imbed effective and sustainable strategies to eliminate health disparities into institutional operations. Creating strategies that are part of the daily operation of health systems to eliminate disparities contrasts with a common view that these are “individual and time-limited projects.”

How Trust Infuses the Issue

Elimination of health disparities requires partnerships with communities served by health systems to help guide design and implementation of strategies.3 Successful partnerships require the development of trust and a commitment by all partners to interact equitably, without any acting in a subservient manner. Achieving a high functioning partnership between health systems and the communities they serve requires specific strategies that can offset the long and well-documented mistrust in health systems held by communities of color and other socially disadvantaged groups. This mistrust stems from historical events, structural racism, disparities in care, and personal experiences of discrimination.

A 2016 National Academies of Sciences, Engineering, and Medicine report described 6 practices in a system of collaborating clinicians, social service agencies, public health agencies, community organizations, and the community in which these systems are located that show promise for improving care for socially at-risk populations.7 Practices that engender greater trust in health systems by underserved communities include a commitment to health equity, use of data and measurement, reliance on comprehensive needs assessments to inform care, and establishment of collaborative partnerships. Trust can be reinforced through the design and continuous improvement of equitable partnerships that involve co-learning, sharing of resources, seeking community input on the best use of resources to serve their needs, community involvement in all aspects of research or health care services design and implementation, and sharing research and program results with the community.8

Gaining the Necessary Trust

System leaders often have the standing within the larger community to facilitate the necessary collaborations among multiple critical partners. Yet, achieving the trustworthiness to do this successfully requires health system leaders to acknowledge the current tension and the reasons for it, demonstrate humility and respect for the assets that exist in communities to be leveraged in addressing health disparities, and communicate transparently, authentically, and frequently with partners. Health system leaders can also proactively reach out to community institutions that already have the trust of the community to leverage their trusted agency.9

Conclusions

Health systems are critical, but not sufficient, to successfully eliminating health disparities within the populations they serve. Health system leaders should adopt evidence-based strategies to build the trusting relationships needed to address this complex social problem that robs people of their health and lives. Such strategies include:

  • Seek, develop, and continuously nurture trust-based relationships with community institutions around improving health outcomes.

  • Establish institutional commitments with appropriate operational strategies, resources, and accountability systems to address health disparities in the community. This includes a willingness to discuss fundamental changes in operations (eg, focus on health in addition to health care delivery).

  • Adopt co-production models that engage and empower community institutions to work as co-equals in the identification and design of interventions and dissemination of results.

  • Establish, monitor, and share progress on metrics that measure progress toward agreed on areas of focus.

  • Establish supporting systems for, and measure compliance with, an institutional commitment that all interactions with the community undertaken by the institution’s health professionals, administrators, faculty, and learners are conducted in alignment with respectful practices for community engagement.

Eventual transition to systems that reward good health outcomes will require health systems to proactively partner with patient populations and communities to eliminate health disparities as a shared value, using strategies that incentivize healthy outcomes for the whole population while also addressing the unique needs of disadvantaged populations. Eliminating health and health care disparities is a necessary step on the journey to VBC and health equity, where “everyone has a fair and just opportunity to be as healthy as possible.”10

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Article Information

Corresponding Author: Donald E. Wesson, MD, MBA, Baylor Scott & White Health and Wellness Center, Texas A&M Health Sciences Center College of Medicine, 4500 Spring Ave, Dallas, TX 75210 (Donald.Wesson@BSWHealth.org).

Published Online: June 7, 2019. doi:10.1001/jama.2019.1924

Conflict of Interest Disclosures: Dr Wesson reported receiving salary support paid through his institution to serve as a consultant for Tricida Inc, a company designing treatments for metabolic acidosis. Dr Lucey reported receiving travel reimbursement for meeting attendance from ABIM Foundation and grants from the American Medical Association and Kern Family Foundation. No other disclosures were reported.

References
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Burwell  SM.  Setting value-based payment goals: HHS efforts to improve US health care.  N Engl J Med. 2015;372(10):897-899.PubMedGoogle ScholarCrossref
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Cooper  LA, Purnell  TS, Ibe  CA,  et al.  Reaching for health equity and social justice in Baltimore: the evolution of an academic-community partnership and conceptual framework to address hypertension disparities.  Ethn Dis. 2016;26(3):369-378.PubMedGoogle ScholarCrossref
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Wesson  DE, Kitzman  HE.  How academic health systems can achieve population health in vulnerable populations through value-based care: the critical importance of establishing trusted agency.  Acad Med. 2018;93(6):839-842.PubMedGoogle ScholarCrossref
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Braveman  P, Arkin  E, Orleans  T, Proctor  D, Plough  A. What is health equity? Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. Published May 1, 2017. Accessed May 31, 2019.
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    1 Comment for this article
    EXPAND ALL
    Useful attention to health and healthcare disparities cannot ignore problems in measurement
    James Scanlan, J.D. | James P. Scanlan, Attorney at Law
    This commentary mentioned “measurement” or “measure” three times but does not address the problems in health and healthcare disparities research arising from the fact that different measures commonly yield different conclusions about whether a particular policy increases or decreases a disparity, and that no health and healthcare research has examined the extent to which an observed change in some measure of disparity is simply a function of the change in the prevalence of an outcome and the extent to which it reflects something else, including the effects of policies aimed at reducing disparities [1,2].  

    Two facts highlight the problematic nature
    of essentially all health and healthcare disparities research. First, even though the National Center for Health Statistics fifteen years ago recognized that as health and healthcare generally improved, relative differences in the increasing (favorable) outcomes tended to decrease while relative differences in the decreasing (adverse) outcomes tended to increase, very few health or healthcare disparities researchers are aware that it is even possible for the relative difference in a favorable health or healthcare outcome and the relative differences in the corresponding adverse outcome to change in opposite directions as the prevalence of an outcome changes. To my knowledge, no research into cancer outcomes disparities has recognized that it makes any difference whether one examines relative difference in mortality from cancer or relative differences in survival from cancer, even though the two approaches commonly yield opposite conclusions about directions of changes in disparities and the comparative size of disparities for different cancers or different subgroups.

    Second, even when researchers have recognized situations where the relative difference in the outcome (favorable or adverse) they happened to be examining and the absolute difference have changed in opposite directions, none has mentioned the relative difference for the opposite outcome. This has occurred even though anytime it is mentioned that a relative difference in an outcome and the absolute difference have changed in opposite direction, the unmentioned relative difference will necessarily have changed in the opposite direction of the mentioned relative difference and the same direction as the absolute difference.

    References

    1. Scanlan JP. Race and mortality revisited. Society 2014;51:327-346
    http://link.springer.com/article/10.1007%2Fs12115-014-9790-1#page-1

    2. Scanlan JP. The mismeasure of health disparities. J Public Health Manag Pract 2016;22(4):416-19.
    https://journals.lww.com/jphmp/Fulltext/2016/07000/The_Mismeasure_of_Health_Disparities.14.aspx
    CONFLICT OF INTEREST: None Reported
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