Health care organisations are on the front lines of addressing health equity, playing key roles in not only access and care delivery, but also as employers and as community members. Discover strategies for organisations to address health equity within their organisations and the communities they serve.
Health equity is the fair and just opportunity for every individual to achieve their full potential in all aspects of health and well-being. The combination of the COVID-19 pandemic and last summer’s demonstrations over social injustice helped to shed critical light on health inequities. Our recent paper on health equity describes the impact systemic racism has on health and actions that leaders can take. Racism is pervasive throughout industries and institutions, including health care. But health care itself is only one factor that affects a person’s health. Some studies estimate that social, economic, and environmental “drivers of health” (also known as social determinants of health) such as income, location of residence, and the quality of social-support networks can account for 80% of health outcomes.1
Health care organisations are on the front-lines of addressing health equity. They play key roles in delivering care, offering products to access care, as employers, and as social safety nets in their communities. Leaders from health systems and health plans are searching for ways to address health equity within their organisations and the communities they serve. They are seeking to understand how they can confront systemic racism and bias and improve health equity.
The Deloitte Center for Health Solutions wanted to understand what health care organizations are doing to address health equity. What steps have they already taken, what have they learned, and what are they planning to do next? We surveyed 20 CEOs and interviewed 28 additional executives from health systems, health plans, and the pharmaceutical sector. Here’s what we found:
• Health equity is a top priority for many organisations. Half of the CEOs we surveyed said health equity was among their top three organisational priorities for 2021. Every interview revealed a leadership and/or financial commitment to health equity.
• Organisations are at different stages in their health equity journey. Some organisations have had executive leadership focused on health equity for years. Others are just beginning to define what health equity means for their organisation. Of the 20 CEOs we surveyed, 17 said they have a dedicated team, task force, or committee and budget dedicated to health equity.
• Leaders are taking many different approaches toward health equity.The executives we interviewed discussed different definitions of health equity. Some viewed diversity, equity, and inclusion (DEI) as strongly linked to health equity while others had different approaches for diversity efforts in their workforces.
Interviewed executives acknowledged that there is a lot of work to be done. Inequities exist, especially among Black, indigenous, and people of colour (BIPOC) individuals. The executives we interviewed shared the following as effective strategies to drive change throughout the organisation:
• Change needs to be driven from the top. A clear strategy and vision for health equity should come from top leadership, including the board. These leaders should also understand the specific needs of the communities they serve so that their organisations can then determine how to help address those needs.
• Leaders need a shared understanding of how health equity is a moral and business imperative. Many executives said they are trying to help leaders recognise health equity as an addressable issue that can also support business goals such as improving clinical outcomes, improved consumer engagement, and better financial performance. Health equity should be instilled in each part of the business, not an add-on measure, to ensure accountability. Having a mix of organisational data on how disparities affect the bottom line, along with personal stories from patients and employees, can make a clear argument for investment in health equity.
• Change needs to be funded and supported. Health equity initiatives that are not well funded or not led from the top are at high risk of failure or neglect, especially when cost reduction becomes a priority. Support from the top could help ensure a commitment of dollars, resources, and goals for a long-term impact.
• A chief equity officer role and a clear governance structure should be created. A named leader, including a clear structure of responsibilities, ensures accountability and execution on health equity strategies for the organisation. Interviewed executives discussed how having a chief equity officer report to the CEO and present frequently to the board can demonstrate the organisation’s commitment to health equity.
• Efforts should be measured and evaluated. Efforts to achieve health equity (whether drivers of health investments, diversity efforts with the workforce, or other specific initiatives) should have clear goals and measures to track progress and to provide insights to continue or shift strategies and investments. Executives discussed the importance of measuring the impact of efforts on business goals (financial, outcomes, consumer engagement), developing community-specific health equity dashboards, and in balancing the available data with the desire to use analytics to identify problems.
Health equity is a complex, multifaceted issue, and organisations should be thoughtful in how they approach it. Achieving health equity requires leaders to deliberately design and build systems where the outcome is advancing health equity. Each leader should be accountable, and every initiative should be measured for impact on investment. Strategies that address multiple dimensions tend to be effective, as does each leader understanding and taking action on their role for achieving health equity within their organisation, offerings, community, and ecosystem. Success can be dependent on long-term strategic and financial commitment to leadership, resources, and accountability.
Ensuring that every individual has an equal opportunity to achieve their full potential in all aspects of health and well-being is a far cry from what exists in the United States today. Achieving greater equity will require a reduction in health disparities—quantifiable differences in health-related outcomes.2
Health inequity is pervasive across race, gender, age, and income, but is especially apparent along lines of race. For example, the mortality rate for Black infants in the US is double that of white infants. And the maternal mortality rate among Black women is more than three times higher than among white women and higher than for all other races in the US.3 Even when incidence rates are similar for a disease, Black Americans tend to die at higher rates than white Americans. For example, Black women have slightly lower incidence rates of breast cancer compared to white women, but Black women have a 42% higher mortality rate. Moreover, Black men are twice as likely as white men to die of prostate cancer.4 Racial disparities often exist across all income and education levels. For example, Black women have a higher risk of pregnancy-related death regardless of income or education levels.5
Over the past year, the world has endured crises that reinforce the importance of health equity. The COVID-19 pandemic resulted in millions of hospitalisations and nearly 600,000 American deaths at the time of this publication.6 People of colour endured significantly higher rates of hospitalisation and mortality than other groups.7 Black and Hispanic Americans, for example, are three times more likely to contract and twice as likely to die from COVID-19 than white Americans.8 The high profile deaths of George Floyd, Breonna Taylor, and other Black Americans in 2020 shined a brighter spotlight on racial injustices and underscored the importance of addressing inequities.
In early 2021, the Deloitte Center for Health Solutions conducted two research studies to understand how health organisations are approaching health equity and to learn about the strategies they’re using to improve health equity within their organisations and throughout the communities they serve. We conducted:
• A double-blinded survey of 20 CEOs (from 12 health systems and eight health plans)
• Twenty-eight in-depth interviews with executives from health systems, health plans, and pharmaceutical companies.
The executives who participated in our two research projects represented health systems and health plans that varied by geography, for-profit status, religious affiliation, size, and communities served. Our in-depth interviews targeted executives who are leaders (chiefs, vice presidents) in health equity, strategy, population health, and DEI.
“[Our current CEO] recognized from an organisational perspective that we need to think more broadly. He hired our first diversity and inclusion officer a year prior to [George Floyd’s death]. He really put a lot of leadership focus on starting to look at equity and starting to look at diversity and inclusion. It quickly, in the midst of our COVID world, became one of our revised goals for us to focus on health care equity.”
—Senior vice president and chief strategy officer, health system
Health system and plan executives agree that health equity is important, and many of them have made it a strategic priority for 2021. Half of the health care CEOs we surveyed said health equity was among their top three organizational priorities for 2021 (figure 1). Six respondents said that DEI of the workforce—which we define as one of the dimensions of health equity—was among their top three priorities.
During our interviews, health care executives told us their leaders were having real conversations, many for the first time, about systemic racism, social justice, and the implications of each on health equity. They described organisationwide townhalls and board/leadership meetings dedicated to the topic. They said they believed their leaders were truly listening to problems, looking at data, and designing solutions. According to the executives, this contrasts with past discussions at their organisations that were more narrowly around quality of care or hiring, and solutions rarely incorporated direct feedback from those impacted.
“We have 300 institutional committees (on health equity) that are all creating value in the organisation.”
—Chief human resource officer, health system
While some health care executives have been working to improve health equity for years, others are just beginning to define what it means for their organizations and the populations they serve.
Some organisations have (or are getting) infrastructure and governance in place. Seventeen out of 20 surveyed CEOs said they have a dedicated team, task force, or committee and budget focused on health equity (figure 2); 10 CEOs said they have a C-suite leadership role dedicated to health equity. Among the interviewed executives, a small number said they have a chief equity officer leading their organisation’s effort. Other executives have a chief diversity and inclusion officer or chief medical/population health officer leading their efforts. Some executives discussed creating specific board committees dedicated to health equity and/or leadership/board retreats focused on the topic.
More organisations are beginning to invest in health equity. Several interviewees said their organisations have recently made investments in health equity. Some organizations have publicly announced efforts, which include monetary pledges, new program initiatives, and appointments of executives who will lead these efforts.9
Some executives discussed investment commitments in terms of dollar amounts, while others cited commitments as a percentage of revenue. One executive said her organization is investing US$10 million per year, a significant increase from its prior investment commitments. Another executive said that her organisation for the first time had a declared percentage of the budget committed to equity. Others said financial commitments toward health equity accounted for between 1% and 5% of total budgets. Most executives saw the dollar investments as a firm commitment and starting point toward something bigger.
The specificity and number of goals varied widely. Strategies to address health equity and methods for measuring progress vary widely. Most organisations are still defining their focus and goal. Organisations that were furthest along in their health equity strategies had set specific goals for measuring change such as improving a health outcome by a specific percentage or increasing workforce diversity by a certain percentage by a specific date. Organisations that are just beginning to address health equity are looking to see what other organisations have done. They are interested in which measures might work best and are trying to identify potential partners/stakeholders both internally and externally.
“COVID has uncovered what we’ve been saying all along in public health and health equity that it can’t just be the role of health departments that have been grossly underfunded for decades to figure out how to build communities that promote health and wellness that ultimately lead to health equity. We have to have the help of other sectors, other leaders, and other businesses.”
—VP, health equity and community wellness, pharmaceutical company
All interviewees agreed on the importance of addressing health equity, but they sometimes differed on:
• The definition of health equity for the organisation and the communities they serve
• Impact of DEI efforts for the workforce
• Strategies to address existing inequities
Defining health equity. Nearly all interviewed executives agreed that equity does not mean equal treatment. They agreed that rather, it means that some individuals need additional or different support or interventions due to the effect of racism on institutions, the drivers of health, and the multiplier effect of those factors. Some executives defined health equity as providing opportunities for individuals to achieve health and well-being. The executives discussed the importance of communicating this difference to their boards, leadership, staff, and the communities they serve.
Two key takeaways from the executives regarding the definition of health equity:
1) Equity goes beyond equal access to quality care. It should also include efforts to improve health outcomes through the drivers of health and combating the systemic racism that leads to disparities.
2) There is no one-size-fits-all or cookie-cutter approach to address the challenges. Initiatives and goals should be customised to the community.
Because of the complexity, one organisation took a step back and worked together to be intentional and define what exactly DEI each mean to their health system and community. The executives also discussed the importance of embedding health equity within the “organisational DNA” and looking at all strategies, processes, and data through a health equity lens. Many executives discussed the importance of being intentional and taking a holistic approach by developing health equity strategies and goals within their workforce, patients, and the community.
"How do you stretch or repurpose your dollars to build relationships. You could build all the programming in the world, but people don't want to trust you ... I want the community to say we designed it for them, but we designed it with them."
—Senior vice president and chief diversity equity and inclusion officer, health system
The impact of workforce DEI efforts. Interviewees acknowledged that workforce DEI strategies should intersect with their health equity agenda but had different views on how they fit. Some view health equity as the umbrella under which DEI sits. For example, some executives saw a strong connection between improved diversity and inclusion within the workforce and improved health equity outcomes among patients. A diverse and inclusive workforce can help to improve trust, empathy, and the connection with communities. Some executives said that championing equity for their workforce could help to improve health equity within the communities they serve. For example, ensuring equal pay/benefits for their workforce, including contractors, could benefit the community. Others had separate leadership and efforts for workforce DEI and health equity with little apparent alignment.
Identifying strategies that can have a meaningful impact is challenging.Improving health equity is a complicated, multidimensional problem. Some executives said it is challenging to determine where they can have the most impact, sometimes to the point of paralysis, because it is so nuanced and local. So many factors, including the drivers of health, impact health outcomes, and executives discussed how they struggle to determine areas to invest. They described not having detailed data or not being able to directly connect specific efforts to outcomes. Executives from organisations that have been focused on health equity for several years were clear and specific about their near-term and long-term goals and visions. They also described having the “strength of leadership” to move forward with “enough data.”
An organisation’s health equity strategy should consider the unique needs and challenges within the communities they serve. Organisations should consider each community’s demographics, its culture, history of racism, and local events that might influence whether people are hesitant to seek care when needed. Every region/locality has some history (and/or current instances) of racism, which can influence how when and where community members seek care. Historical racism and existing social unrest in the region/community should be thoughtfully considered. This could help address the needs of the organisation (workforce) and the health/social needs of the community.
Most of the executives we interviewed work for organisations that serve multiple communities. They agreed that it is important to have a representative from each region who can speak to the nuanced needs and challenges of their communities. These executives said they try to identify opportunities for systemwide or organisationwide initiatives, such as hiring practices, clinical pathways for quality improvement, and scorecards. They acknowledged that most of these efforts were localised to meet the unique needs of each community.
"We have a very tall hill to climb and trust has to be at the core, given the past injustices to Black bodies. It will take time and investments … more than just money."
—VP, health equity and wellness, pharmaceutical company
Many interviewees stressed the importance of listening to community residents when developing strategies to address health equity. This can be just as important as listening directly to consumers and listening to the physicians, social workers, and community partners who have been working on equity concerns for decades. Organisations should not dismiss the voice of the patients and provide them with a seat at the table versus just offering token involvement. According to one interviewee, “the voice of the patient leads to an understanding that will lead to change, better outcomes and loyalty.”
“What are the things you can do concurrently while working on the long-term vision?”
– VP, chief diversity, equity, and inclusion officer, health system
"Without a sustained commitment, you lose time and momentum. I guarantee you, health equity will come and go, everything does. What will make it last, what is going to make it stick … keep it relevant? That’s how I’d like to approach it in terms of investment."
—Chief diversity officer, health system
Interviewed executives acknowledged that there is a lot of work to be done. Organisations that are furthest along in their journey have a commitment from top leadership and identified a connection between health equity and their business model, including their financial performance, patient satisfaction, and outcomes. Many of the executives we interviewed said health equity strategies not only need to align with organisational strategies; they also need to be ingrained within the business and measure progress to drive true change within the organisation. Executives acknowledged the need for accountability to ensure that efforts sustain.
While there is momentum for organisations to address health equity, it needs to be more than just the topic of the moment. Many interviewed executives recognised that addressing health equity requires more than just dollars. All executives agreed that having a clear strategy and vision for health equity from top leadership, including the board, is essential for an organisation to move forward and for sustaining it as a priority.
Some interviewed executives discussed how their top leaders identified the problem years ago and decided to take action then. Others discussed how through the use of data, compelling stories, and focusing on today’s pandemic and social justice movement, leaders recognised the problem and made health equity a priority. All agreed that efforts could not move forward without support from the top.
Sustain efforts.A mix of governance levers could help create accountability within an organisation. Many executives noted that if equity is separate, or on the margins, the commitment—both in terms of leadership and financing—will go away when times get tough. Others discussed how measuring progress could create some level of accountability and staying power for the initiatives. For example, tying equity to quality could help ensure that health equity remains a priority for the CEO, board, and other top leaders. Measuring progress could also help embed measures of equity into organisations’ internal scorecards, including quality measures, to keep progress visible. Hospitals will always be accountable for quality, but embedding equity training into certifications makes it a core business requirement. Some executives also discussed tying performance reviews and compensation (of leaders and physicians) to metrics on health equity to help ensure accountability on all levels.
“When equity IS our culture, just the way we do business, and NOT a special set of circumstances … that is how to keep it as essential … and our culture should bleed out of our walls—to members, regulators, partners, and others … that is when you see the groundswell.”
—VP, integrated community partnerships, health plan
“To ensure equity is not a fleeting issue; you need to embed it throughout the organisation.”
—Chief diversity officer, health system
Health equity should be instilled in each part of the business, not an add-on measure, to help ensure accountability. Executives told us that they try to “speak the business’s language” to get their leaders on board with the drive to improve health equity. They agreed that a shared understanding of the connection between health equity and the business model (e.g., quality, outcomes, workforce) is critical.
Some interviewees said they use specific examples of taking a health equity lens to various parts of the business that resulted in improved performance and patient experience. For example:
• One executive had her data analysts investigate ER data to see what factors may be contributing to longer visit and wait times. They found that the majority of patients with longer wait times did not speak English as their primary language. By adding primary language to the intake form, they were able to shave off a three-hour difference, which improved performance and also made the ER experience more equitable.
• Another executive used data on disparities in patient experience scores to demonstrate gaps that ultimately affect revenue, as those scores are correlated with patient loyalty, likelihood to recommend, and payment in value-based models.
“Equity and drivers of health/social determinants are a human dilemma with a business and strategic imperative.”
—Chief diversity officer, health system
However, our survey results indicate that few CEOs are connecting health equity to business goals. Only four surveyed health care CEOs said their health equity goals were related to business objectives such as improved patient outcomes, satisfaction, brand, or market share (figure 3). The majority of CEOs said they are investing in health equity to help improve support for the drivers of health, social good, and to support the organisation’s mission. Interviewed executives agreed and said organisations that don’t make this connection could be missing an opportunity to advance health equity while helping to achieve critical business goals.
Know your audience. To get support and resources from the CEO/board and to get buy-in from physicians, the workforce, and other stakeholders, executives discussed how the presentation may need to shift depending on who is in the audience. Many said that they found there is not necessarily a one-size-fits-all solution. One executive, said that “some are already on board with health equity investments and don’t need convincing; others need data to illustrate the problem areas or blind spots and what solutions may help, and others need to hear personal stories of employees and patients to be convinced health equity should be an investment priority.” Executives discussed how it was critical to have a stakeholder strategy that included both those who were supporters of health equity and others who need more convincing.
Identify allies. Improving health equity can require tremendous effort and a long-term commitment. However, there are fast-start opportunities in the short term that can help build momentum. These include identifying allies for health equity among other leaders within the organisation. Such allies can include physicians or operations leaders.
• For example, one executive has had success by identifying “ambassadors” who were operations leaders and may see synergies in their initiatives to pilot efforts that would improve care delivery. These allies can help build relationships with other leaders within the organisation and can help ensure efforts gain broader attention and support.
• Another executive said a physician leader was inspired to add “equity” into the performance reviews of her physician team. The leader used this as an opportunity to discuss data and patient experiences with her physicians and to point out potential blind spots and share their learnings with other physician leaders.
Interviewed executives discussed how adding depth and action to commitments is critical. Some organisations have good intentions but only gain soft commitments, such as promises and messages without specific goals, investments, or detailed actions. Many organisations include equity in their missions and have been working to improve the health of their communities. However, some executives discussed how past experiences show that in tough times, health equity initiatives can fall in priority or lose funding. Firm commitments from leadership can reduce the chance of this happening. This means setting goals, having accountability, and developing measures of all the efforts behind the dollars. Commitment and support from the top (CEO and board) and an organized plan can also be essential. Organisations also should answer some tough questions:
• Where can our efforts have the most impact?
• How do we ensure our efforts will endure?
Answering those questions upfront can help sustain the initiatives and hold stakeholders accountable.
More immediately, health care CEOs should consider a chief equity officer role to demonstrate the organisation’s commitment to health equity. The role could report to the CEO and present frequently to the board. This leader ensures accountability and execution on health equity strategies for the organisation. Organisations that have had a lengthy focus on health equity had such a leader in place. More importantly, this leader was given resources (dollars and people) to support efforts and a seat at the executive table to align the organisation.
Many interviewees also highlighted the importance of having a clear governance structure and dedicated infrastructure, including a leader, to support these initiatives. With multiple internal and external/community partners, the initiatives should require a clear governance and accountability structure to help ensure sustainability and success.
“Data can help us see our blind spots. And then [we can] begin to better understand why the outcomes are differing.”
—Chief diversity and inclusion officer, health system
While health care executives acknowledge that data is critical, some struggled with how to use data to measure the impact of their health equity efforts. Some had specific tactical goals and clear measures to track progress related to improved quality, outcomes, drivers of health, and the workforce. Others were still defining their goals and measurements.
Data can be a powerful tool for gaining broader organisational support. Many executives discussed how their organisations or physicians had never looked at their data by race before simply because they had never been asked to. By looking at their data in new ways, many described the experience as eye-opening. Data that demonstrates how patient outcomes differ by race can demonstrate the importance of addressing health equity. Data can also show where well-intentioned efforts are falling short. For example:
• One health system executive used data to show that Black mothers and infants had a mortality rate that was three times higher than other races. This information was presented to the board/CEO and used to create a clear baseline. The organisation set a goal to reduce it by a certain percentage.
• Another health system executive said doctors pride themselves on being inclusive and sensitive to health equity. However, the data showed that Black women were far less likely than white women to receive mammograms. One doctor was puzzled because she treated all patients the same—by giving them the same reminder to get an annual mammogram. “That’s the problem,” the executive said. “For someone who have never had a mammogram, a reminder might not work. They might need a discussion on the importance of mammograms and help with identifying where to get one that is convenient. Different patients need different messaging.”
In both cases, data paved the way for tactical and impactful discussions for improving inequities.
Many executives also discussed the difficulty of developing scorecards specific to their communities and in measuring long-term initiatives. Although, there is a lot of academic research and data on health inequities and clinical data, one executive said she had no publicly available template for building her initiatives around business metrics. Although every community has unique needs, many health care organisations face common challenges such as chronic-condition disparities or consider common approaches such as investment in the drivers of health. A lack of transparency among health organisations can stall progress if each organisation has to learn through trial and error versus learning from one another.
In addition to collecting and measuring data, many executives said it is helpful to hear real-life examples from people who have experienced inequity and discrimination. Executives discussed sharing these stories with their leaders. For example, one employee recalled how a patient recoiled when they tried to give them a vaccine, because the patient didn’t want a Black man to touch them. A nurse explained that she changed her name on a resume because it was “too Black” sounding. Once she changed it, she had an influx of job offers.
“This is about leadership ... You’re not going to have the perfect construct within which to operate (as least not initially to begin with). So, you need to decide whether to get started or do you wait until it is perfect. We had to get started with good enough and not wait on perfection.”
—Chief medical officer, health plan
Health equity strategies that address multiple dimensions can be most effective and when every leader within the organisation understands their role and takes action to achieve health equity. Leaders should consider the following questions across the following four dimensions:
• Organisation: How can we reimagine our approach to diversity, inclusion, and belonging to advance equity among our workforce and address its unmet social needs?
• Offerings: How can our products and/or services more effectively meet the needs of our patient population across demographic groups?
• Community: How can we serve our local communities as health equity leaders?
• Ecosystem: How do we strategically amplify our positive impact through our vendors, partners, and public platform?
Achieving health equity requires leaders to deliberately design and build systems toward this purpose. Executives should recognise that it is a long journey but there are near-term opportunities that can lead to real change. Health care leaders should consider a long-term commitment—not just of dollars but also of leadership, resources, and accountability.
Amid uncertainty and change, health care stakeholders are looking for new ways to transform the journey of care. By focusing on the differentiated needs of plans and providers, our US health care practice helps clients transform uncertainty into possibility, and rapid change into lasting progress.