At an overwhelming majority of hospitals in the United States—up to 80%—racial and ethnic minorities are underrepresented among patients who access many common services, U.S. News & World Report said, unveiling a new suite of health equity measures July 27.
A deep dive into the U.S. News findings appears here, accompanied by a conversation with Ben Harder, managing editor and chief of health analysis at U.S. News (The Cancer Letter, July 30, 2021).
To comprehend the significance of disparities articulated in the U.S. News study and define the scorecards’ impact on bragging rights at cancer centers, The Cancer Letter asked four leaders in oncology to evaluate the health equity measures.
What are your takeaways from the inaugural health equity findings by U.S. News?
Robert Winn, VCU: This is an important issue finally getting the attention of more people, and it is a good first step. But we have more work to do and will get more nuanced over time gathering this important data.
More health systems are in need of a health equity report card like we use in quality and safety. I am looking forward to the day when these health equity report cards are widely used, by most if not all health systems.
Karen Knudsen, ACS: I applaud USNWR for delving into how well hospital systems are addressing health equity. This is a critical issue that leads to greater incidence, suffering, and death from cancer, and we need better ways to advance our nation’s work in this area. It must be a priority, and from my perspective, it’s long overdue.
Ruben Mesa, UTHSCSA: I am pleased they did this analysis to really help quantify what a gap can exist in cancer health equity at some of our finest cancer centers across the country. The NCI Cancer Centers Program has helped deepen institutional and NCI Cancer Center Commitment to Community Outreach and Engagement by including this as an area of review for Cancer Center Support Grants.
USNWR can make an impact towards expanding cancer health equity by quantifying the current gaps.
Cheryl Willman, UNM: I am not surprised by data demonstrating that racial/ethnic minorities are significantly underrepresented in four of five pre-eminent, primarily referral hospitals in the U.S., as these hospitals provide a lot of tertiary/quaternary care.
The access bar is often very high and the facility capacity to take “care of everyone” at these hospitals and health systems is not sufficient, even if they desire to provide care to everyone in their catchment area.
I do, however, think that one cannot conclude from these data alone that the “quality” of care delivery is significantly less at public safety net hospitals, based solely on the criteria used by USNWR to rank hospitals, some of which are highly subjective, some of which are based on mortality index, which is going to be higher when treating underserved and vulnerable patients who too often present at advanced stages of disease, and some of which is based on personal opinion.
The characteristics of patients treated by large academic public/private referral centers and public safety net hospitals are so dramatically different. Public safety net hospitals, like University of New Mexico Hospital where I have worked for many years, provide critical health care for diverse, underserved, rural, and racial/ethnic and sexual/gender minority patients who often have no other means of access to health care.
Patients who enter these sites often present with more advanced stages of disease, have significant comorbidities, and have had limited access to high quality primary care and means of disease prevention and screening.
For instance, at the UNM Comprehensive Cancer Center in New Mexico, over 50% of our patients are racial/ethnic minorities, over 50% are from deeply rural counties, and nearly 25% of patients who present with a cancer diagnosis have had no primary medical home and have not been under the care of a primary care physician.
Over 40% of New Mexico’s population is insured under the Medicaid Waiver, a federal program which has been a godsend to provide a means of health insurance to vulnerable patients who have had no insurance before; the New Mexico program has grown 66% since 2013.
It will be very important in future analyses and comparisons of “quality care delivery” to actually adjust or consider all of these different patient characteristics, beyond race and ethnicity.
Is the “four of five” finding striking to you? Also, are these results new to you, compared to what you’ve known from experience and from the literature?
Winn, VCU: Nothing was particularly striking to me. Most of these inequities have been present for many decades. What’s new is that the study pointed them out, but generally these issues are not new. Health disparities have certainly been talked about in literature, but they have frequently been fragmented. There is a porosity of literature on these topics.
Knudsen, ACS: Without seeing the methodology and the data, this one is hard to comment on specifically. My initial reaction is that four of five seems very high, but I would withhold true opinion until I had the opportunity to learn more about the patient population vs. the population each of these hospitals serve.
What I do feel, however, is whether it’s one out of five or four out of five, it’s not good enough unless we are equitably meeting the needs across the populations we serve!
Mesa, UTHSCSA: Sadly, this number does not surprise me. Financially, centers have been incentivized to prioritize commercially insured patients that, of course, deprioritizes the care of Medicare, Medicaid patients and let alone unfunded or self-funded patients. This is the double whammy of both financial barriers, combined with the impact of social determinants of health limiting access, time to receive care, compounded by barriers in health literacy overrepresented in populations of minority patients.
Willman, UNM: I found this result striking, but I know this sadly rings true: that “Medicare-insured residents who are Black, compared to similarly insured residents of other races, have experienced more hospitalizations that might have been avoidable if they’d had access to better preventive health care.”
In my experience, this is undoubtedly true of Hispanics and of indigenous Native Americans or undocumented individuals, results which are not new to me given we have served these populations for many years.
Having just stepped away from leading cancer care at a major safety-net hospital, I would say yes—health equity is, in my opinion, something that is reasonable to consider in the evaluation of hospitals.
Karen Knudsen
I am also not surprised that “the racial gap in potentially preventable hospitalizations grew worse since 2011 in nearly a third of U.S. communities.” There are several reasons for this in my opinion, unfortunately many of which are due to our nation’s political environment and the constant attack and stripping away of provisions of the Affordable Care Act.
As I noted above, the Medicaid Waiver has provided a vital means of insurability for so many underserved and diverse individuals and communities. So, secondly, the failure of so many of our nation’s governors and state legislatures to participate in the federal Medicaid Waiver program has had a tremendously detrimental effect on the health and wellbeing of the people and communities they serve.
Third, an issue that is often uncomfortable to discuss in the Cancer Centers’ community, is the federal attack by the Trump administration on the congressionally-mandated 340B Drug Reimbursement Program, which had a disproportionate impact on the nation’s Cancer Centers and their ability to deliver care to the underserved.
As you know, in 2018, CMS reduced reimbursement by 30% of lifesaving cancer drugs to public safety net hospitals and cancer centers, effectively negating the benefit of the 340B drug purchasing program which allows hospitals, cancer centers, and health systems to purchase cancer drugs and other therapeutics at a discounts that range from 20-40%. Congress had expressly intended for the margin generated by the 340B Drug Purchasing program to be used for expansion of comprehensive medical services to the underserved.
At the UNM Comprehensive Cancer Center alone, we suffered an immediate $12 million annual reduction in CMS revenues in January of 2018—a severe impact when we also provide over $10 million annually in unreimbursed cancer care in our ambulatory clinics alone.
In contrast, cancer centers who are Prospective Payment System (PPS)-Exempt (including the cancer centers associated with the five health systems who were studied in this report), a program that is now closed to others, were exempted from this most recent CMS reimbursement reduction. This differential impact, and undue harm to cancer centers impacted by the CMS reimbursement reduction, only further exacerbate the difference in capability and resources to deliver cancer care to all.
The inequity in differential CMS payment and reimbursement models to many rural and frontier states and these differential CMS payment models need to be reconsidered.
Should health equity measures be weighed in the ranking of hospitals? If so, what are some important considerations that should be included?
Winn, VCU: Absolutely. We’ve recognized the gap in disparities is not shrinking. Not even close. Just as we implemented standards for quality and safety, we should monitor what health systems are not doing when it comes to health equity. It will put the metrics and framework in place for all health systems to improve health equity over the years.
Knudsen, ACS: Having just stepped away from leading cancer care at a major safety-net hospital, I would say yes—health equity is, in my opinion, something that is reasonable to consider in the evaluation of hospitals.
Notably, NCI does in fact ask the major centers to report on how well the center aligns outreach and research to the needs of the patient population. So, many of the key measures are fairly well known. A potential metric of success is how well the patients served reflect the composition of the catchment area, and the extent to which needs are met. A further extension, which the NCI Centers also very much consider, is how well clinical trial enrollment represents the catchment area served.
From my past experience, I honestly believe that the major centers are making every effort to strive toward access and equity, but there are major barriers that stand in the way of equitable access and care. Many of these barriers are beyond the means of the cancer centers to address.
For example, gaps in transportation, lack of housing near the care delivery sites, and lack of patient navigation are each major, well documented factors that contribute to reduced cancer care access and resultant disparities in outcome. Each of these are known factors that contribute to inequities in cancer care and outcomes; notably, ACS functions in all 50 states to overcome these barriers through direct patient support programs, and seek to further extend our reach to areas most in need.
As such, I applaud USNWR for making this a priority, because we all must make it a priority.
Mesa, UTHSCSA: I think this is a wonderful idea. The USNWR rankings are both highly visible, but also impactful in everything from marketing cancer care, to attracting faculty, to contracting with third-party payers.
The “cancer scorecard” each center receives has evolved over the years to include an expanded group of parameters to measure quality, from patient experience, nursing ratios and magnet status, to the quality of programs (FACT accreditation, NCI Designation, radiation therapy technologies).
It would be both appropriate and impactful to recognize the importance of caring for the entire regional community (including corresponding percentages of underrepresented populations to match the community, and programs to expand cancer health equity) in assessing the “quality” a cancer center/hospital brings to a community for cancer care.
In so doing, USNWR would likely increase the emphasis and corresponding resources that institutions would devote to these efforts and the inclusive outreach of their cancer care in their respective communities.
Willman, UNM: Yes, but I think it will be very important to define the measures by which we define the “diversity” of populations served or in a catchment area to go far beyond urban/rural, race/ethnicity to include aspects of the social built environment, environmental exposures and behaviors, socioeconomic factors, access to health care, insurance status of populations, and the health care infrastructure of a region.
I also think we should consider splitting the analysis between the regional, adjacent communities that a hospital/health system serves from their broader national referral population.
Although potentially non-specific to the cancer patient population, the equity profiles for the top 10 ranked cancer hospitals or health systems with matrix cancer centers show that racial/ethnic minorities are also underrepresented at these institutions. Based on what you know of academic oncology, what are some possible explanations?
Winn, VCU: Many of our academic centers don’t accept Medicaid and have structures in place that are unwelcoming to patients in their neighborhoods. Top academic centers have proven they are interested in research, but most have undervalued research that directly investigates social and economic determinants and what causes the gaps. So there is a combination of the environment and not accepting types of insurance and not having a sufficient number of people interested in health disparities. It has all contributed to the lack of minorities.
Knudsen, ACS: This is a critical issue. It was a priority for me at Jefferson, as past president of AACI, and now at the American Cancer Society. We have to increase diversity of oncology care—and research—at all levels. ACS is partnering with minority-serving institutions like Morehouse to fund positions to build a stronger pipeline. This needs to be a priority for all of us, including cancer centers.
Mesa, UTHSCSA: These are great cancer centers impacting the cancer mission through their research, clinical trials, cancer care and education programs. Drivers of underrepresentation of minority patients at these centers is multifactorial.
Without question, finances are a major driver, where commercially insured cancer care—critical to generate care financial margins needed to fund the academic mission—is a huge factor.
Additional barriers including access, impact of social determinants of health and health literacy to seek care, hourly wage based employment discouraging seeking care during work hours all contributing to the disparity.
Additionally, sometimes the experience of presenting oneself to a massive academic cancer center can be intimidating with many aspects of the experience sometimes being far from welcoming to a patient of limited means (complex registration procedures, challenges with transportation or parking, assumptions of access to computer resources or smart phones).
Willman, UNM: All of the reasons I have discussed above: access barriers, lack of “cultural comfortableness” of a minority/underserved patient in entering a “premier” center, centralization of high quality, complex cancer care versus innovative means of dissemination of care to diverse and distributed populations, geographic and distance barriers, and variability in insurance status and “acceptability” of different forms of insurance at “premier” centers.
The data are largely based on Medicare claims, without Medicaid or private insurance. Does that make these findings particularly significant? Also, do you expect to see similar trends in Medicaid and private claims data?
Winn, VCU: It does. If the Medicaid population is added in, the findings may be even more augmented in terms of a lack of minority presence. I absolutely expect Medicare would track better because frequently private insurance and Medicaid are not as desirable. The data for private insurance and Medicaid would undoubtedly be grim.
Knudsen, ACS: Again, it’s difficult to comment specifically on that without seeing the methodology and the data. In general, it’s important to recognize that the patient population—including the population of underserved patients—also includes those who are insured privately or by other means, uninsured, on Medicaid, on Medicare, or dually covered by Medicaid and Medicare. To look at only one aspect could impact the overall accuracy of the data.
Mesa, UTHSCSA: I suspect these other data once included would only further highlight the gap in health equity, with significant disparities in both groups leaning toward underrepresented populations with Medicaid, and largely more Caucasian and affluent amongst the commercially insured.
Willman, UNM: I do believe that the fact that all patients assessed were insured by Medicare, make the disparities and outcome differences seem even more profound.
And yes, I am sure that when individuals insured by Medicaid, the Medicaid Waiver, private insurance, and uninsured patients are examined, the differentials and disparities in patients served and outcomes will be tremendous and concerning.
What can cancer centers do in response to these findings from U.S. News?
Winn, VCU: We should all take a moment of pause and reflection. As we moved through the COVID crisis, we learned about health disparities and social structures that we need to address. But the greater conversation is recognizing that it is not just minorities in the community. There are problems with our health systems, and we have to be more mindful with how they are inadvertently contributing to the disparities.
Knudsen, ACS: Let’s first recognize that health inequity is a systemic issue that demands collaborative solutions from the public, private, and nonprofit sectors, as well as the communities served:
Note that this ranking looks at patients served by the hospitals, so by design, it does not include those who were not able to access care to the level necessary to get to that point.
Insurance coverage alone will not solve these issues. We have to address social determinants of health and critical concerns such as health literacy, cultural and language barriers, and mistrust in the health care system.
There are specific strategies and action steps:
- Build trust in underserved communities. Note that ACS supports this through our educational awareness campaigns that build trust in screening, for example.
- Listen and incorporate these populations’ lived experiences into their hospital experiences. We need to develop solutions together with underserved populations, rather than develop solutions for them.
- Prioritize patient navigation to improve outcomes and to be able to demonstrate to underserved communities that healthcare systems will be there to support them every step of the way.
Mesa, UTHSCSA: I believe cancer centers, especially NCI Designated Cancer Centers, will be able to utilize this information (especially if incorporated into the rankings) to lobby for additional resources, programs, access strategies, outreach to the community to expand access and care to these underrepresented populations to match their communities if considered an important factor for their USNWR ranking.
Dr. Robert Winn and I have been working to gather a group of similarly-minded NCI Designated Cancer Centers, to join the Mays Cancer Center in San Antonio and Massey Cancer Center at VCU, to develop a collaborative effort to advance Cancer Health Equity across our communities, our states, our country. We look forward to sharing more with The Cancer Letter as these efforts mature.
Willman, UNM: We simply have to be committed to health equity; there is no other ethical path or more important ethical imperative.
I am thrilled that the national Cancer Center community is now engaged in deep consideration and discussion of Diversity, Equity, Inclusion (DEI) in all of our missions (including clinical care delivery, research, education and training, and our community engagement programs), and, of how we might attain health equity by lowering the access bar to more vulnerable and underserved populations, by partnerships, and by the development of innovative means to widely disseminate high quality care.
I also think we have to renew our commitment as cancer centers to not only training in cancer medicine and research, but to training public healthcare workforces and allied healthcare professionals who will be essential in the future on the front lines of clinical care delivery.
Other comments?
Winn, VCU: I’m glad this is being brought to the forefront. At Massey, we are rolling up our sleeves and understand even the miracles of science have limitations. Gaining the trust of our communities means we have to address and break down barriers to make cutting edge science and healthcare more accessible to all communities. All at-risk communities, both urban and rural.
Knudsen, ACS: Yes! ACS has some concepts for potential solutions: An Equity Scorecard.
The goal of the equity scorecard, which we created in alignment with other organizations, was to try to give some sort of benchmarking for how well any given system or cancer center is doing compared to standard, and to give recommendations. So, I think that that could be part of the learning community, if you will.
And an important role for ACS moving forward is to try to assist centers that are falling short and that could use a little guidance. We’ve done the same thing with screening and return to screening, to try to assist by building toolkits for health systems and cancer centers to deploy, so that they can enhance their screening rate.
We see ourselves as doing the same role with regard to health equity.
Mesa, UTHSCSA: It’s great to see The Cancer Letter continuing to advance important conversations in our cancer community—few are as important as advancing diversity, equity, and inclusion in our cancer care (prevention, screening, care, and survivorship), our research and clinical trials, and in our cancer training and education programs.
Willman, UNM: It is an interesting time to reflect on this data as I am in transition from leading the UNM Comprehensive Cancer Center in New Mexico for 20 years—with a tremendously underserved, diverse minority population—to leading the Mayo Clinic Cancer Programs nationally, starting August 2, in Minnesota/Midwest, Florida, and Arizona and globally.
I believe cancer centers, especially NCI Designated Cancer Centers, will be able to utilize this information (especially if incorporated into the rankings) to lobby for additional resources, programs, access strategies, outreach to the community to expand access and care to these underrepresented populations.
Ruben Mesa
I must say we have been having deep discussions at both institutions about how to “lower the access bar” and about DEI and Health Equity Issues. As the Mayo Clinic serves very diverse and different communities at each of its three U.S. Sites, it has a great opportunity to make a difference.
Health equity and improving access “for all” to Mayo’s great clinical care are challenges that I personally and the Mayo Clinic are deeply committed to achieving. We are also developing exciting new programs and highly innovative platforms for virtual/digital care within one’s home environment: Mayo Clinic Care@Home and Mayo Clinic Cancer Care@Home.
I believe these programs have the potential to revolutionize high quality care delivery in a very cost-effective fashion, to enhance the dissemination of high quality care across large geographic regions, and to achieve health equity by assuring access to these care models and programs to diverse and underserved communities.
