This beast motivated me to become a doctor and dedicate my career to making health care safer and more equitable – from leading quality for one of the largest public health systems in the U.S. to serving as the first patient safety officer at The Joint Commission, which accredits more than 22,000 health care organizations.
Decades later, I understand that the beast of inequity isn’t only in rural Alabama. It’s in the machinery of our health care system, which spends $11 billion every day – and yet still doesn’t deliver health to millions of Americans.
Our health care machinery has twin engines: what we measure and what we pay for. Together, these tell us everything we need to know about what and whom our health care system values.
Across race, politics, geography, gender and income, Americans know what they need to be healthy: safe homes, healthy food and well-paying jobs. Research shows that some 80% of health outcomes are tied to these and other nonclinical drivers of health, with nearly all doctors reporting that such factors impact their patients’ health.
But the realities of people’s lives are still mostly invisible to our health care system. The Centers for Medicare & Medicaid Services uses hundreds of measures to assess the quality of health care and to direct health care spending. But it has zero measures that capture these drivers of health in federal payment programs.
At a ground level, that can mean when a patient can’t manage her diabetes – because her electricity got shut off and she can’t refrigerate her insulin – her doctors won’t know. Recognizing this problem, CMS has called for new measures to address these factors, and highlighted the importance of “self-reported demographic and social-needs data” in its Innovation Center strategy and new health equity initiative.
In response, a group of front-line physicians recommended that, for the first time, Medicare begin measuring whether doctors and hospitals ask their patients questions like, “Do you need help with food, housing, transportation, electricity and other utilities, or interpersonal safety?”
In April, CMS took a critical step forward by acting on this recommendation and proposing the first-ever Medicare quality measures incentivizing hospitals to ask their patients about these issues. Next, it will consider the same type of measures for physician practices.
With these measures, we can finally begin to know if things are getting better or worse for patients when it comes to the basics that they need to be healthy. This data is also a key step in our health care system beginning to pay not only for clinical care, but for what actually drives health – like patients’ access to healthy food or transportation to the doctor.
Asking patients what they need to be healthy should not be so radical, especially given COVID–19’s profound economic harm and its disproportionate impact on communities of color. Indeed, an overwhelming number of stakeholders – from the Texas Medical Association and Humana to Mass General Brigham and solo physicians in rural North Carolina – have called on HHS to enact these measures.
But, as always, the champions of inaction are vocal. The defenders of the status quo are exactly whom you might think: the big hospital and medical associations and their lobbyists, who both acknowledge the impact of these factors and want to be free to ignore them.
Their approach is familiar: the call to wait. We need more research, more refining, more testing, more time.
What they are really saying is: People who are suffering – who are making brutal, daily tradeoffs between feeding their family or paying for their medicine – need to wait. We’d rather they remain invisible.
In 1963, Martin Luther King, Jr. wrote from a Birmingham jail: “For years now I have heard the word ‘wait.’ . . . This ‘wait’ has almost always meant ‘never.’” Three years later, he shined a light on health care, condemning the American Medical Association for a “conspiracy of inaction” in civil rights.
Today, inaction looks like status quo health care institutions declaring it is premature to enact these drivers of health measures – even while 65% of physicians say these measures are important to improving health outcomes and ensuring high-quality, cost-efficient care.
These historic measures are now in the hands of Secretary of Health and Human Services Xavier Becerra and his colleagues at CMS to move forward. Doing so is essential to furthering the administration’s commitment to reveal, quantify and address health inequities.
Eighteen years ago, Institute for Healthcare Improvement founder Don Berwick threw down the gauntlet on patient safety, declaring, “Some is not a number; soon is not a time.” Indeed, now is the time for HHS to lead the way in measuring what actually drives health – and in making visible at last what we Americans need to be healthy.
