Conversations with health care executives

- [Mackenzie] Hi everyone, and welcome to today's webinar, inadequate outcomes, the crisis of health inequity. This is Mackenzie Bean, Managing Editor with Becker's Hospital Review. And on behalf of Becker's, thank you all so much for joining us today. Before we begin, I'm gonna walk through a few quick housekeeping instructions. We'll begin today's webinar with a panel presentation and we'll time at end of the hour for question and answer session. You can submit any questions you have throughout the webinar by typing them into the Q and A box you see on your screen. Today's session is being recorded and will be available after the event. You can use the same link you used to log into today's webinar to access that recording. If at any time you don't see slides moving or you have trouble with the audio, please try refreshing your browser. You can also submit any technical questions into the Q and A box as we are also here to help. With that, I am so pleased to welcome today's esteemed panel. Dr. Wayne Frederick is the president of Howard University. Dr. Patrice Harris is the CEO of eMed and past president of the American Medical Association. Adele Scielzo is CEO of the Advisory Board. We're also so thrilled to be joined by, Michael Currie, Chief Health Equity Officer for UnitedHealth Group who will serve as today's moderator. Dr. Frederick, Dr. Harris, Adele, and Mike, thank you all so much for being here. We're really looking forward to this panel. So with that, Mike, I'll turn the floor over to you to get things started.

- Great, thank you very much and good afternoon everyone. It's a pleasure to be moderating this panel with such esteemed panelists. We're hoping that we're going to have some conversation and discussion and share some information that you not only find important and interesting, but useful and impactful in the work that each of you do, listening to this session. We all know that health equity is extremely important. It has been important. And as a chief health equity officer for UnitedHealth Group, I get the real fortune of working across our entire enterprise. So, yes, working in corporate but across our United Healthcare Business, across our Optum business, and in the various departments within those lines of business to really do two things, really focus on two things. Number one, identification of where health disparities exist. You can't manage what you don't measure. So it is critically important to start foundationally with understanding where the disparities are, what populations are impacted, what the order of magnitude of the disparities are. And then once you identified that, that big number one, and that's where the secret sauce comes in. And that's doing all of the things that you can do leveraging all those various areas at UnitedHealth Group across the entire enterprise. If it's in a different organization, whatever those levers are, whether it be health literacy work, social determinants of health work, social responsibility work, supplier diversity work, research and development, D and I and workforce diversity, whatever those pillars and whatever those levers are that you can leverage to then address the disparities that have been identified, all of that work advances the overall goal of achieving health equity. So with that as a backdrop, I'd like to start us off today with you, Dr. Harris, posing our first question to you. And again, foundationally, health equity has always been important but it has taken on a different light and taken on increased awareness. Not that health equity has become more important. It has become increasingly more top of mind and the level of awareness about those things that relate to health inequities really being top of mind to many businesses, and individuals, and organizations, and agencies. So with that in mind, knowing that there's nothing new about health equity but this orientation to now, I don't wanna say now, but to move from a discussion about health equity, what it is and what could be done to action to impact health inequities right now. How do organizations, companies, individuals, how are they able to term to determine that there's a problem, a health equity problem, a health inequity problem, in the areas where they work and participate in solution?

- [Dr. Harris] Well, first of all, Mike, let me say it is an honor to be a part of this discussion, this important discussion today, because as you note health inequities are not new. We just have more people who know about them. And I have had, I believe a wonderful opportunity, a privileged opportunity to view health inequities to view health and several different lenses. Of course, as a leader in organized medicine, just completing my service on the board and as past president of the American Medical Association, but I've led local large county public health department. I am a psychiatrist. And so I see inequities through that lens. I'm a patient advocate. And for many years I've been engaged and involved in policy. So it's been a wonderful perch to see, unfortunately, and sometimes tragically these inequities. And we know about these inequities, Mike, because we have the data, we have the evidence. Now, as you said, not new, but, and by the way, the data is incomplete. And we have to do a lot more across the entire health and healthcare ecosystem to make sure we are collecting data in a manner that is useful. And that is a public private sector, federal state, and local level. But that's how we know that we have these inequities. More people know about them now because of COVID. COVID has amplified so many of what I call the fault lines in our healthcare ecosystem, lack of public health preparedness, health inequities, and under-appreciation here to for the importance of mental health care, but here we are looking at data where we know that communities of color have been disproportionately impacted by COVID. But pre-COVID communities of color disproportionately impacted by hypertension, heart disease, diabetes, some forms of cancer, lack of health insurance. So it's the data that clearly shows us that we have an issue here, and without our usual distractions, both positive and negative during COVID, more people know about them. So this is an important discussion, but what you note is, what are we going to do after this discussion? We cannot just talk about the problem, we have to act. And I'm sure as we go through the panel today, we will be talking about specific actions.

- [Mike] Thank you, Dr. Harris, I appreciate that. Dr. Frederick, I'd like to get you in on this conversation as college president, and wearing a number of the other hats that you wear. I love to get your perspective on examples of these health inequities from where you sit and then maybe some thoughts and ideas, again, wearing the many hats that you wear on possible approaches and models to address these inequities.

- [Dr. Frederick] Yes, sure, I think to follow up on a lot of the points that Dr. Harris laid out, I am a practicing GI cancer surgeon. I still operate with my role as university president, and what I have seen since January, people presenting with more advanced cancers, and with symptoms that have been persistent for much longer as we shut down our ambulatory care system. So a lot of the preventative tests that people would have had, or at least diagnostic tests like colonoscopies, et cetera, have been delayed. And the other is we've kind of kept people away from our hospitals as we prioritize COVID. And so people developing symptoms like jaundice and so on have been hesitant to come to the hospital, unfortunately. And I'm seeing the impact of that. And primarily in underrepresented groups, when we look at life expectancy in ward seven and eight, and you all know how small DC is, ward seven and eight is 95% African-American. The life expectancy of a black male in that ward is 22 years less than a white woman in ward three. And just think of how small DC is. And it just goes to show you that even in the nation's capital, we have a problem. The third thing is part problem part solution. We have a food desert in ward seven and eight. However, our university's nutritional science students have been out there shopping with residents. There are only two grocery stores for about 170,000 people. And they've also been going to the corner stores and speaking to the owners there about where to put things on the shelves. The reason I mentioned them is because I think we have to put our patients back at the center of our healthcare system and ensure that all of the points of contact that they have were using to extend the opportunity to close the disparity. So when you go to the dentist, I think is an opportunity for screening, for diabetes, for checking your blood pressure. When you go to the pharmacy, I think is an opportunity there as well for some contact. And, similarly, when you have dieticians, et cetera, who can go out and work in the community and meet the community where they are, I think we have an opportunity as a different paradigm to look at how we deliver care. And especially for those who are most vulnerable.

- [Mike] Thank you, I have a real appreciation for that in the role where I sit in, that's a perfect segue over to you, Adele. You know a lot of times when in the work that I do, I will hear people using the words, health disparities and health equity synonymously. And those of us in this space understand that health equity is the ultimate goal that you want to achieve, that you aspire to. Identifying and addressing health disparities is a major component of being able to achieve and advance your efforts towards health equity. It's a large puzzle piece or mosaic piece in the overall health equity puzzle. So, Adele, can you help us? Can you give us a sense of how we should best be defining health equity, at both ends of the industry and those of us who work and toil in this space?

- [Adele] Yeah, Mike, I am happy to do that. And I think it is, sorry. You saw me point my finger, 'cause my dog decided to use this moment to bark. Kayak, please be quiet. I think the question that you asked is a really important one because at our work at the advisory board, as you indicate, we often that much of the industry incorrectly identifies health equity. They either define it in really broad, almost gauzy terms. So mission statement, press release, or in ultra specific ones, like we focus on the social determinants of health. When health equity is really about matching individual needs, including those connected to age, national origin, religion, disability, sexual orientation, socioeconomic status, and more. And addressing the real impact that those factors have in determining health outcomes. Advancing equity is notably different than striving for equality, which involves offering the very same treatment to every person regardless of their situation or background. And if you take the concept of equity and you expand it beyond just the definition and you think about kind of what can an organization do and what does an effective organizational strategy look like to address health equity? We find in our work that there are three pillars that organizations should be including in their health equity strategy. The first is ensuring equitable outcomes for patients by ensuring that all of their specific physical behavioral and social needs are met. Think of this as treating the whole person and not just the illness. The second pillar is addressing community-wide social determinants of health and their root causes, by reducing long standing structural inequities and intergenerational poverty. And the third element of an effective health equity strategy is creating and supporting a diverse and inclusive workforce that truly reflects the characteristics of the community, and ensuring that diversity, equity, and inclusion, for me, all levels of the organization. Now at first blush the first and the second of these pillars make a lot of sense. It's the third that we get a lot of questions about and sometimes might feel only tangentially related to health equity, but we found that supporting a diverse and inclusive workforce is actually a really critical step in building credibility and trust with the community. So it's collectively bringing all three of these elements together, that we feel like leads to improved equity among the workforce, individual patients, and long-term population health outcomes.

- [Mike] Thank you, Adele. This work specifically that we do with UnitedHealth Group and not just specific to UnitedHealth Group, I'm sure if there were other health insurance carriers included in this discussion, we would all be saying the same thing as it relates to addressing health inequities. But a specific focus for us at UnitedHealth Group has to do with three domains that we really focus on when we are identifying and addressing health disparities. And that's access, utilization, and health outcomes. Every day, all day, we are constantly using our data and clinical insights to identify disparities that exist in those domains and then leverage our internal tools and partnerships with others and a whole host of other approaches to address those disparities. But that's what we see. That's the outcome that we see. So, Adele, if I can piggyback on what you just responded to, what would be some of the root causes, some of those social factors that really bring those health disparities to light that we actually see.

- [Adele] Yeah, so this is what we commonly think of as social determinants of health. So these are causes that aren't medical in nature, but things like food, housing, employment, all have a massive impact on a person's health outcome. And importantly, they don't just have an impact on outcomes. They also have a real impact on the community. And many health care organizations, I might argue all of them, act as anchors in their community. The local hospital may be the number one source of employment, and they invest in their surrounding communities. Not just because it means better patient care, but because it uplifts the community as a whole.

- [Mike] Thank you, thank you, Adele. I sincerely appreciate that as well. I hope that's helpful to the audience listening so that you're not only understand what health equity is and what health disparities are and how they contribute to health inequities those various things that you need to do to achieve health equity or advance health equity, but you also understand the root cause of many of the disparities that we see. Now, Dr. Harris, when we have a conversation about health disparities and health equity or health inequities, we can't have a robust and authentic conversation about that without also speaking to the healthcare system as a whole. So I'd love for you to say a few words about how the structure of our own healthcare system has produced and may still be producing, may even be exacerbating the health inequities and the disparity health outcomes that we see.

- [Dr. Harris] I will be happy to do that, Mike. But I'm going to go a little bit off topic and just remind everyone in our listening audience to remember self care, not only during this very difficult time for our entire country, but always. Sometimes many of us in the health and healthcare ecosystem put ourselves last. And so I just wanted to point that out and I also have to point out a positive that has come out of COVID for all the negatives. And I love, Adele, that your dog is there because I think as we've participated and connected virtually, we've been able to see the whole of who many of us are. And I think that's important too. So that's just a side note and a little bit off topic. I also, I think Adele is so right about the gauzy definitions of health inequities, right? Because we have to remember that we wanna get to health equity and that's an outcome but it's also a process. And I'll just say, we have to begin with these conversations and with actions with the shared definition, I imagine that everyone in the audience is familiar with, you know terms that we all use. And sometimes we forget, and I'm guilty of that too to start with a shared definition, you know, when we talk about value based care or helping health inequities or health equity and health disparity. So I'm just going to briefly read the World Health Organization's definition because I think it's important. Absence of unfair and avoidable differences in health among social groups. And so I think it's important to talk about unfair and avoidability because we sometimes forget that aspect. The AMA, we talk about equitable opportunities for everyone to achieve their optimal health. Adele also talked about some of the root causes, and I have to say, we absolutely have to address some of those barriers. You're talking about access and transportation and daycare and the lack of access to healthy, nutritious foods that Dr. Frederick mentioned. And although today, not perhaps the time Optum and everyone listening more than have to as a group have sometimes uncomfortable conversations about moving even further upstream and talking about bias and discrimination and structural racism. And that's why I love this question, Mike, because you mentioned two words in the question that are important, systems and structures. And so we really have to think about this systemically and we have to think about all the structural barriers. And so is there transportation? What's happening in the education system? Because we know that is also a social determinant of health. We talked, and Dr. Frederick talked about food deserts. What about a healthcare desert? And so what does that mean for action? It means that we all have to move closer to our patients and meet people where they are so that we can address some of these issues around access. We also have to include conversation around access to affordable, meaningful health insurance. And Dr. Frederick mentioned something that I call a no wrong doors approach, right? There should be no wrong doors to access healthcare. I have to say I'm very proud of the work that I did as public health director in Fulton County, where we had a couple of we call them at the time one stop shops, where we had our public health teams, our behavioral health teams, our primary care partners in with education, our education team, and our housing team. And so if families came in for an appointment for women's infants and children's program, the federal program we ask, what other needs do you have? And so that's how we began to solve some of these barriers regarding access, some of these structural barriers. And I'll say one last thing, Adele also talked about looking internally and looking at workforce issues. And that is something that every organization has to do. Look internally, and look at any policies or practices. Look at who is seated around the boardroom. Who's in the C-suite, who's on the board. These are all things that organizations must do. And finally, I will say accountability and commitment. And Mike, you probably, if you're like most folks in positions similar to yours, you are the quarterback. Each organization will be different and it's appropriate for that, but you are the quarterback, but it's important for the CEO of any organization Optum, UnitedHealth Group to say, I own this issue. And I am going to make sure that everyone who reports to me has metrics and we are going to support Mike. And we are going to embed these issues in this work into the core, into the DNA of our organization. That's how we get to solutions.

- [Mike] That's awesome, Dr. Harris. Those who've heard me speak more than once have heard me say a number of times if the health equity movement and work is going to be as effective as we all want it to be, it has to just become how we do, what we do, period, end of story. There will come a day where you don't need a Mike Currie or any other chief health equity officer, because all of these tenets and efforts in activities and sensitivity, all of those things that are necessary for a health equity to come alive in its fullest form will just be how the health care system does what it does. Thank you, Dr. Harris. So Dr. Frederick, we talked about what health equity is. Adele helped us frame that up, that difference between health equity and health disparities some of the both social factors and systemic factors associated with health inequities, and that really frames up the problem, what we see. I'd love for you to share your thoughts on examples of what we're doing based on what we see examples of addressing social factors or systemic factors or maybe even discrimination and bias that helps address health disparities.

- [Dr. Frederick] Yeah, you know, I think there's several things that are happening in that space that are important. The first I would mention obviously being an educational institution is the pipeline. We have to improve the pipeline. How would the university sends more African-Americans to medical school and has trained graduates and more Black physicians than any of this single institution in the country. We are doubling down in that effort. We're seeing an opportunity to push that food that we had 11,000 applications this year. And we would only need to take in 126 students. We probably have the fifth, I think now the fifth most selective school in the country. What people tend to miss though, is that up to 126 students who will come to Howard this fall, about 78 of them, this is the only institution they got an interview and would have received an offer. So we have a secondary application that's focused on that disadvantaged group, as well as whether you're willing to go serve in an underrepresented area. It's a major part of our screening to admit our students. So I think the pipeline is one area where we have challenges but at the same time, I think there's opportunity for us to change this because the more voices you have, every Black or Hispanic patient or anyone who is in an underrepresented category, a poor White patient, does not have to have a physician who looks like them but has to have a physician who's culturally competent around engaging with them. And that's the second area that I see as an opportunity. I think curricular changes in graduate medical education is a critical part of what must happen as we go forward. Because you think about it, someone breaks their hip and comes in to get a procedure done. You have to then examine the full holistic view of the patient, the support, et cetera. I think that that's another critical aspect that must occur. And also I think the young people who are coming are bringing a lot of hope, the number one major on this campus at any given time is biology. So there are lots of young people interested in pre-med and while the pipeline is definitely choked, I think there's an opportunity to open it up. The second thing I would say in terms of what is necessary is probably a little unconventional. The pandemic has bought the interconnectedness of each of us, I think, to be. And also as a result, it has displayed the fact that we have to amplify each other's humanity. So while there are big systemic things that must be done to change, the reality is that we have an opportunity every day to amplify each other's humanity. And a lot of times what's happening in terms of the distrust in our community is the distrust in institutions. Is a distrust in government and law enforcement. And that then begins to bleed over into things like distress in the medical community and distress of vaccines. And what we're seeing is that as trusted messengers, who are there consistently, those are the folks that are gonna be trusted. So the other thing that I think is happening on a systemic basis, is how we're using community partners. Whether it's churches, elders in the community, you know, NGOs, I think we're seeing that that partnership is not a nicety. It's an absolute necessity, and that we have to continue to flip through that. And you're seeing that occur in many different our communities throughout the country. So, you know, I think as Dr. Harris has said, there's a lot for us to be saddened about what has happened over the past year. But at the same time, I think that there's a lot of hope and that hope still lies in the young people that are coming behind us. And it's still lies in the basic need nature of our human condition. And that is, oh, I'm defining all humanity.

- [Mike] That's great, that is very helpful to hear as a number of things that you just mentioned really rang deep to me. I mean, as a biology major I'm glad to hear a lot of interest in that as a major, the social impact in working with partners whether they be healthcare partners or non-healthcare partners, critically important. You know, Adele, really bringing additional information and awareness, and even beyond awareness, and maybe even beyond information, maybe more examples in the seat that you sit as the CEO of the Advisory Board Company, are there examples that you'd like to shine light on that are really critical and central and key to this overall goal of achieving health equity both from a UnitedHealth Group perspective as a whole, but maybe the companies within the United UHC and Optum?

- [Adele] Yeah, I mean, I am, you know, in the role that I play, I am lucky enough to see kind of great work happening all across the UnitedHealth Group organization. And, Mike, as you know better than I, UHG has been committed to health equity for kind of many decades, and has done a lot of work with independently but probably more importantly, in partnership with community organizations and national partners. And as you said so eloquently before, right, there are four prongs, if you will, to the current UHG strategy. The first is really focused on delivering personalized care based on individual needs. The second is promoting equity and diversity in the healthcare workforce. Third is improving the health of underserved communities and the fourth is leveraging data and emerging analytics to address disparities in care. So that is the kind of the overarching strategy that UHG is focused on but to make that real, right? All leaders within the organization, and all business units are held accountable for actually making meaningful progress. So at the advisory board, we advise organizations to embed equity into strategy and to invest in programs. And we're doing the same thing within our own research organization. So that means if you're interested in research on helping the clinical workforce recover or understanding the future of tele-health, you'll find an equity angle in that work. So building off what you were saying before, right? Prompting an equity lens and all that we do. So try to accomplish that. Today, we have 11 different teams at the advisory board that are specifically researching different aspects of health equity including the role of the C-suite specifically and the four big pushes that we're making on this topic. The first is reframing how executives should think about the problem, and the need to stratify the data. We're doing two quantitative analyses, one at the national level and the other, that's looking at all payer data to help identify the biggest priorities for tackling outcome disparities. And then finally, we're doing a qualitative study on how to embed health equity into strategic decisions. I may actually flip, you know, if you'd so indulge me I may take this as an opportunity to ask you a question in your role. Are there any examples of new ways that you're seeing that payers, government providers, and community organizations are coming together to do a better job here?

- [Mike] Sure, you know, I'd highlight three things. One would be the improved collection of self-reported race and ethnicity data. Everything starts with the data that allows you to really identify where the greatest need is, not just from a health measure or metric perspective, but the population or populations in greatest need. And in order to do that especially when you're going to focus on racial health disparities, we know that health disparities can show up based on age and gender and geography but race and ethnicity is a key component. Because you can tailor and personalize programs and services based on race, ethnicity, and age, and gender. So it becomes a key variable that you would like to be able to use. So one is the enhancement and improvement of self-reported race, ethnicity collection so that we can be better at identifying the disparities and then developing the tailored programs and services to address them. The other would be understanding the diversity. And in some cases, lack thereof of the providers that health insurance companies have as part of the contractual relationship or network providers that they have contractual relationships with. To Dr. Frederick's point. We're not going to be able to in one year, two years, five years, maybe seven or eight years, radically improve the diversity of our network, but it allows us to see where there are opportunities for improvement. And part of that improvement could be promoting and encouraging cultural sensitivity, cultural awareness, training, and education, you know, Dr. Frederick views the world cultural competency and we want individuals to be culturally competent. There is discussion depending on the audience whether competent is the word, because in some feel like once they satisfy education or training, they're competent. They reach where they need to reach. They don't need to do anymore. We all know this is a journey. You just become increasingly culturally aware and appropriate over time. But understanding the diversity of the provider network is an area where there's increasing interest discussion and potential partnership. And last would be alternative payment methods, and how we leverage payment whether it's through CMS or commercial customers, however the arrangement may be. How we leverage alternative payment methods to move the agenda and move the momentum along as it relates to areas within health equity. But those would just be I could rattle off five, six, eight, more double though, those would be three I would highlight. Adele, thank you for that question. I appreciate that. You know, Dr. Frederick, I want to pivot so, and I'd like to point these last few questions to our physicians, because I really wanna get clinical now and specific to clinical outcomes. So Dr. Frederick, let me come to you first. And as it relates to cancer, and whether it be prevention or early screening, or treatment, I'm really interested in your thoughts specific to cancer, a disease like cancer. What are some examples of addressing bias and inequity that can improve either the prevention, screening, treatment, associated with a disease like cancer? How do you leverage your seat as both the president and a physician at Howard University to drive the agenda of this type of work specific to Howard.

- [Dr. Frederick] Well there's a very topical issue. I think just today a decision was made about screening for colon cancer, bringing down the initial age to 45, but still, we have to be mindful that while these guidelines are there we've got to also close the gap with insurance companies and others and physicians as we make decisions, I'll give you two examples. One is Chadwick Boseman, our dear alum. Even at age 45, which he never got to, while before that he developed a metastatic colon cancer. Ibram Kendi, who has written the book on the anti-racist actually is a stage four colon cancer survivor. He has a metas liver, colon cancer has had both operated on as well as chemotherapy. I'm not sure that it Ibram is 40 yet. So it means that even with those screening guidelines, we have to, I'm glad to see them coming down. What I would like to see written in there is more an assessment of risk. And a better assessment of risk that doesn't tie us into a specific age, but allows for the judgment of physicians to adjust what the screening modality should be, without a lot of pushback and back and forth. Because I think it's critical to do that. We've done some of that in breast cancer but we clearly are going to need to keep that going. The second thing that I think is important is education. For someone in their 30s symptoms of a breast cancer or a colon cancer should be really abnormal findings seeing blood in their stool or having a difference in their bowel habits or feeling a mass from self breast exams. Again, all are not perfect ways of picking up, but we have to educate. And I think that that's probably one of the biggest things that we can do in these communities to try to at least sensitize people to the facts that some of these cancers may occur at an earlier age, and therefore they need to get out and have that, you know, have some activity to make sure that they are well screened.

- [Mike] Thank you, Dr. Frederick. Dr. Harris, coming to you now. Telehealth, through COVID we talked about a number of unfortunate realities associated with COVID. One of the things that was a positive that came out of COVID was the expanded use of telehealth and telemedicine. So Dr. Harris, what would be your examples of how digital health is allowing many physicians and clinicians in the community to better address health equities or health inequities and improve access to prevention and early screening?

- [Dr.Harris] We know there's no question that COVID-19 certainly accelerated adoption, actually on both the health professional, clinician, a physician side and the patient side, as a psychiatrist I've been using tele-health for years. And of course, it's not a panacea it's about right, patient right time at right cost. But certainly I believe that the positive, again, as you note, is the accelerated adoption. And so the key will be what next going forward. And so there's no question that there's promise at the intersection of health and healthcare and technology and innovation, but there's also peril, you know, Dr. Frederick mentioned something it's a little bit similar not quite, but we can't, you know, ultimately get to where we are just using algorithm care. There's got to be some judgment there. And Adele mentioned some personalization of that but that's the peril, but there's so much promise which is why I'm so excited to have taken on the role as CEO and co-founder of eMed. And I like to say eMed is a digital health, digital point of care company with a purpose, right? Because we know that a lot of innovation is going on and some folks are interested in the bright, shiny objects but at eMed, we are interested in solving problems, some of healthcare's greatest challenges. And so we are a digital point of care company that enables home diagnostic testing. You know, the earlier we know something as patients, the better, right? We can have actionable data, hopefully identify any health issues early. That not only saves dollars, when you think about the financial toll, but it also certainly saves lives, saves distress, looking at the human toll. So very excited about our work at eMed and the future there. It's important for those home diagnostics to be verified and validated. So again, there's so much promise and I'm very proud to be a part of that. At eMed, our first foray was looking at the lack of access to COVID testing, right? Dr. Frederick talked about the zip codes. And what I saw early on was the zip codes that were disproportionately impacted by COVID early on were the very zip codes that did not have equitable access to testing, or you had to have a car, you waited in a long line. So, again, so much opportunity there in using technology and innovation. And I'm again, very excited to lead eMed and do our part and partner with payers and with communities regarding that engagement.

- [Mike] Outstanding, thank you for that. Well, panelists, this has been a very rich discussion. This has been pleasing to me and I hope it has been as pleasing for those listening in. I thank you, thank you very much for your time. And I thank Becker for creating this opportunity for us to have this discussion for individuals to listen to. So at this time, Mackenzie, I'll turn the floor over to you.

- [Mackenzie] Great, thank you so much, Mike. Dr. Frederick, Dr. Harris, Adele, this really has been such a powerful informative discussion. So thank you all for your time. At this point, we will turn things over to our Q and A session. For audience members, you can send any questions you have by typing them into the Q and A chat box you see on your webinar console. Looks at the pad at the end of the questions come in to round about the metrics measurement piece. Are there specific measures or metrics that healthcare organizations should focus on when it comes to measuring or tracking or addressing health equity?

- [Mike] Yeah, I'll take a shot at getting us started on that. And what I will tell you is there is wide variation. And when we look at this from a UnitedHealth Group perspective and those that we serve, it's going to be different. I mean, obviously there's some similarities especially when you talk about maternal health outcomes, we see consistency in disparities or opportunities for improvement in both our commercial and Medicaid populations. But when we're looking at other metrics, we see different opportunities for improvement and those populations that stand the greatest opportunity for improvement across our commercial, Medicaid, and Medicare business. So the measure or the domains of measurement are consistent for us. Again, we're looking at access, utilization, and the outcomes that those core analytic fields never change or domains never change, but the results that we get do show some variation by line of business. And then once we see what we see, then we go about the business of best addressing those disparities and personalizing and tailoring our care and services at a customer level when it's commercial, at a state level when it's Medicaid, and with other partners when it's Medicare. But we do see some variability aside from that maternal health focus that we had. Panelists, any other thoughts, comments?

- [Dr. Harris] I agree my, unfortunately, oh, sorry, Adele. I think we are unfortunately early on but at least we are embarking on this journey, as you say, because at some point we do need to establish some benchmarks but you start where you are. And I think each organization can begin to look internally, look at their own customers and start there. Hopefully at some point I envision a world where there's a consortium and we are looking across systems to figure this out. And even the traditional systems, you know, the educational system pulling those in. The other challenge and we are early on in this is how do we even collect data around the social determinants of health, right? And so I think organizations will start there. But we need that data in order to look across our country to compare what's happening at the state level. Even at the local level we are going to have to establish some standards and some benchmarks, but we are early on but at least we are beginning the process.

- [Mike] Yeah, Adele, do you want to add to that?

- [Adele] Yeah, all I was gonna add is right if you take the rubric which you shared of access utilization and outcomes, and you look at your community, you know, the population that you serve and you look for the biggest kind of disparities in that data and craft a strategy to address the issues that present in your community and go from there. Which are gonna be depending on where you are.

- [Mike] That's right, that's right. Dr. Frederick, if I can, I'm gonna take just a little bit of liberty here. And as a proud Washingtonian who was born and raised in Northeast Washington, how would Howard University as a leading institution, harness its resources to first and foremost, analyze and identify where health disparities and the various wards of DCR, and then bring together and convene partners to do something about it. How do you make that work or make that real specific to DC?

- [Dr. Frederick] Yeah, you know, we're doing that on an ongoing basis. I mean, during the COVID pandemic, the Black Coalition Against COVID, which was formed, Howard has been an integral partner in beginning that. Everything from looking at the availability of masks, cloth mask, looking at and assisting with developing ads to go on buses, et cetera, you know, hosting webinars series. We participated in that. I also think on an ongoing basis, one of the other things that we must continue to do is to make sure that we're bringing the community into the university as well. I came here for undergrad in 1988 and I've seen the community change and evolve, but Howard has been, I would say, a stalwart in the community. So pipeline, again, start city. We have a middle school on our campus that's focused on math and science. And we get students into lottery. Those students get exposed to our med school, our dental school, very early for middle-schoolers. But what we are seeing is that 96% of those students go on to college. Regardless of where you go to high school. We have a dual enrollment program for high school juniors and seniors, so that they can get exposure early credit. We think that's important. Trauma prevention is a major part of what we do as well. We've partnered with the city to stand up five centers of excellence focused on with maternal mortality on trauma prevention, on opioid abuse, on sickle cell, and on diabetes. All of which affect the DC Black community more so than anyone else. And I think that's important for us to continue to do. So in all levels, whether it's working with government, with limited people directly, or working with other community based organizations like churches, and others in the Black Coalition Against COVID, we are at the forefront of really trying to make a difference and making sure that we can embrace the community in the way that they more than fully deserve us to embrace them.

- [Dr. Harris] Add to that because as a child psychiatrist, I have not heard Dr. Frederick say that about the middle school on campus. I think that's a wonderful idea. And I think that it's important. Now, I'm gonna sort of wear my AMA hat. And it's important for organizations with resources to support initiatives like Dr. Frederick mentioning the middle school. And I will just tell you the AMA of course we are a national physician's organization but our headquarters is in Chicago. And we know that the west side of Chicago, if you look at that zip code, a significant lower life expectancy than those just a few miles away living along the magnificent mile. So we invested financially in a program, an initiative on the west side of Chicago. And so that's what I think organizations with resources can also look into partnering real partnership, right? Sharing power, committing to financial resources in a community so that innovation can occur.

- [Mackenzie] Wonderful, I appreciate you all sharing insights and advice about, you know, where organizations can start with this. We've also had a few different questions come in about the data aspect. One of which is, how can healthcare organizations improve the collection of data while also acknowledging that race can be a proxy for racism?

- [Mike] Adele, from a consultant advisory board perspective, any thoughts on that?

- [Adele] It's such a great question, right? And it's one of the challenges that we have today. And one of the reasons that we don't have as richer data sources, or as much data at our fingertips, and when we do, there is hesitancy to share it because we haven't really figured out the right way to navigate this issue yet. I wish I had the silver bullet or the perfect answer, but I really don't.

- [Mackenzie] Well I appreciate you weighing in there. Please go ahead.

- [Mike] No, I was actually going to ask Dr. Harris in her role as past president, I know AMA just put out a new strategy and focus around advancing health equity, any thoughts or perspectives from you on a response to that question?

- [Dr. Harris] You know, I think you start with where you are. Not everyone wants to share their data but whatever data you have, you look at that for instance and you look at, you know, women and you look at maternal mortality, you look at infant mortality in the data that you have, you know, you start there. And then the next thing you do is engage with the community. If you find that and I'm making this up, but if you find that over 60% of your covered lives, aren't sharing that data. And of course this will have to be local because trust is key, right? We hadn't talked about that earlier today but we know there's a lot of mistrust and distress of the ecosystem, right? Of, you know, prior health, sort of traditional health and healthcare stakeholders. So you start engaging at the local level and you go into communities and you are a true partner. And you say, tell us what you need, right? Or tell us the reason why you might be afraid or I won't even characterize it as afraid but what makes you reluctant to share that data? And then you can solve those problems. Sometimes we sort of guess at why people aren't sharing data, let's go in and partner and ask. Now, I will say, and Dr. Frederick, of course, and Howard's a great example of this. The community that again has had issues with mistrust in order to gain their trust you have to be trustworthy. And as part of that, you have to have a sustain effort, right? Some community members say, well, you know, X group, pick a group large, organization only comes in academic institution, when they need us, right? And then they leave and then they don't come back. And if they did a study, they don't share with us the results of the study. So it's about that sustained effort. And, yes, as past president of the AMA, we just published our strategy. Our three year health equity strategy. I would encourage everyone go to our website and review that strategy. It's comprehensive, it's truth telling. It talks about what organizations can do. It talks about what the AMA can do, but that is proxy. I think for what other organizations can do, again, not a one size fits all approach but I believe that's going to be very instructive to a lot of organizations. So I commend that to everyone for your review.

- Thank you, again, I think Mackenzie is calling back in, she's back in, so Mackenzie, I'm turning it back over to you.

- [Mackenzie] Thank you so much. It looks like there's time for about one last question which is from an audience member who writes that disparities in health care for African-American are not just related to social determinants of health. It can also obviously be across all socioeconomic statuses for a community. For example, Prince George's County is a very affluent black community outside of DC, and they had the highest COVID death rate in Maryland. So this audience member is asking the panelists to respond to the idea that limiting the discussion to social determinants of health for the African-American community does not address health inequity for the entire Black community in the US. So we'd love to hear some of your thoughts on that and reaction.

- [Mike] Dr. Frederick, being close by, I'd love to hear your thoughts on them.

- [Dr. Frederick] Yeah, you know, I'd say, that clearly is unconscious bias in medicine as well. Let's be clear. I mean, I think, and there has also been courage to talk about this. The Journal of the American Medical Association when Dr. Harris led that organization as president, they published a study back in 2013. I believe it was now looking at unconscious bias in medical students right before they started classes. I would argue that medical students right before they start class are probably the most altruistic people in the world. But one of the implicit and explicit bias test they had was looking at a Black lawyer and the White toll booth operator and asking the question, who is more capable of understanding informed consent? And the majority of those medical students chose the White toll both operator over the Black lawyer. So we recognize that unconscious bias in terms of how we approach patients, and ultimately how we treat patients. We see that, we see that in a another study from Johns Hopkins, looking at trauma patients. In the first 24 hours, there's almost no difference in mortality rate for trauma patients with the same kinds of injuries, same severity of injuries. But if you start getting out beyond 48 to 72 hours, you start seeing a divergence in outcome based on whether you have insurance or no insurance. And that again, maybe because people are making a decision not to get a particular study, or not to apply a certain intervention based on whether somebody is insured or not. So unconscious bias without a doubt is an aspect of it. Having said that, we have to attack the problem holistically as you heard from the other panelists. So we have to drive at the social determinants of health but we also have to sensitize healthcare providers, legislators, et cetera, that some of the decisions that we're making and putting laws on the books have ramifications. And those ramifications are important. And as we said, it's not just about the healthcare system. If you're driving back and forth, and you're worried about being pulled over by a cop, that is a daily stressor. And I believe that Dr. Harris and her colleagues call that the wearing phenomenon, or the constant feeling of being under attack or stressed about just competing daily activities. Those things wear you and it will decrease your life expectancy. So I agree, yes, there's social determinants of health but there are other biases that we cannot ignore.

- [Mackenzie] Wonderful, thanks Dr. Frederick. That is all the time that we have left for today. So I just wanna thank our speakers again for such an insightful presentation today and thank you to Optum for sponsoring today's webinars. To learn more about the content presented, please check out the resources section on your webinar console and be sure to fill out the post webinar survey. Thank you all again so much for joining us. And we hope to have a wonderful rest of your afternoon.