Embedding Health Equity as a Patient Safety, Clinical Quality Issue

For Leah Binder, president and CEO of patient safety rankings organization The Leapfrog Group, embedding health equity as part of patient safety is a no-brainer.

“This year, the issue of equity and inclusion have emerged as major national priorities, and Leapfrog is no exception,” Binder told PatientEngagementHIT in an interview. “As an organization, we recognize our role and our obligation to assure that when we set standards for safety and quality, those standards apply to one hundred percent of all patients, not just those patients who may be more privileged for whatever reason, whether it's race, ethnicity, socio-demographic status, or language.”

The question of health equity has also been an important one for value-based care. Organizations can only get the best clinical outcomes and fulfill their value-based care contracts when they ensure all patients have the same opportunity to obtain and maintain health.

That means organizations have to do things to level out the playing field, like deliver community-based healthcare for patients who otherwise wouldn’t be able to access care in a traditional brick-and-mortar facility. It means conducting social determinants of health screenings and referring patients to key social services, because patients can’t achieve wellness if they are housing or food insecure. It means provider groups need to continually track where health disparities are, and understand the forces driving them.

In totality, these actions should create a safer patient experience, according to Binder.

Which is why Leapfrog recently unveiled key updates to its hospital and ambulatory surgery center surveys for 2021. The organization, which routinely surveys those facility types, has added questions about health equity, as well as ethical patient billing, as part of a fact-finding mission that Binder said will help Leapfrog play a role in improving care moving forward.

“We had to recognize, for us as an organization, what we can do to contribute to the improvement and finally achieving health equity in this country,” Binder explained.

“The first step that we're taking in that journey is the question that will appear in the 2021 survey, which are a series of questions about health equity. We are asking hospitals if they stratify their data on quality and safety by race, ethnicity, and language, as well as LGBTQ status. We want to understand whether they understand where the gaps might be in the care they're delivering.”

Binder emphasized that these are just baseline questions that Leapfrog will use to better understand where the industry is at with health equity right now. She said that in this first year of surveying, the group will not report on findings for specific hospitals or ambulatory surgical centers. Instead, Leapfrog will report the trends and give an industry update.

Currently, those industry efforts are lacking, Leapfrog found in research it did to prepare for the new survey questions. That is not to say there isn’t a good reason for this limited progress; collecting health equity data is hard, and not many organizations can gather quality and safety data stratified by race, ethnicity, and preferred language spoken.

“Frankly for me, that was pretty surprising when we first started to research this topic in depth, because I kind of assumed that hospitals already must know that,” Binder said, emphasizing how important of an issue equitable health outcomes is.

“Now, in some cases, it's more difficult than other cases to find that information,” she added as a caveat. “There are lots of challenges to finding the information, but challenges can be overcome. We have to do that.”

Leapfrog plans to use this first years’ worth of data to help organizations in that effort so that health equity in healthcare quality and patient safety can be a baseline standard
“Because if we don't make that effort, then people are going to be left behind and we can't allow that to happen anymore,” Binder said.

The Leapfrog Group is also zeroing in on another key issue on the healthcare consumerism front: what Binder called ethical patient billing.

“Patient safety begins with a respect for the dignity of every patient,” Binder asserted. “Part of respecting dignity is to respect people's finances. These are not sideline issues to someone's health. Finances determine, in some respects, some of your health status.”

The data backs her up. October 2020 polling found that just over half of healthcare consumers are worried medical costs will put them into bankruptcy. Earlier that year, a March survey showed that about a third of patients delayed medical care because of high out-of-pocket healthcare costs.

And even once the novel coronavirus struck the nation, patients weren’t so sure they could afford even a viral diagnostic test. In April 2020, 14 percent of patients said they wouldn’t get a COVID-19 test, even if they believed they needed one, because of the potential patient financial responsibility.

High healthcare costs are a tricky issue because, as Binder said, healthcare organizations do need to get paid. They have to keep the doors open to offer care access somehow, but the mechanisms by which they handle patient billing need to be patient-centered.

“Hospitals and health systems have to financially survive, we understand that, but they also need to respect their patients at every stage and every moment of their lives, and that includes how patients pay for their care,” Binder acknowledged. “There needs to be the ultimate highest level of respect for them.”

Right now, the literature is telling Binder that US healthcare has demonstrated very poor ethical decisions about how they obtain payment from patients. And as noted above, this is not just a financial issue. Patients under enormous pressure will experience negative health consequences. And if that patient is treated with disrespect from a hospital billing department, she surely will not be healthy, Binder said.

A more ethical billing process isn’t one that shortchanges the healthcare provider, she added. It’s one that puts the patient at the center.

“Right now, according to our research, what we think are best practices for billing is issuing a bill that a layperson can understand,” Binder said. “Most people are not experts in healthcare, and they need to be able to read the bill. It needs to be written in language they understand, so that's the first principle.”

Healthcare price transparency is another key best practice. Binder stated that currently, it is possible to give a patient a fairly accurate estimate of healthcare costs, unless that patient is receiving care in an emergency.

“That's been considered a crazy idea for so long in healthcare, but that's changed,” she said, citing the CMS hospital price transparency rule that went into effect in January.

“But that should have been happening from the beginning,” Binder added. “It's now happening and that's good, but that should be a really baseline standard, should know how much you're going to be billed.”

Finally, Binder spoke out against surprise billing, a situation in which a patient receives a medical bill she did not expect or did not expect to be so high. This happens a lot when a patient who is unresponsive is unable to tell emergency responders to take her to a hospital emergency department that is in-network. It also happens when a patient, using her due diligence, visits a hospital that is in-network but is unknowingly treated by a doctor who is out-of-network.

“If a particular physician is not in-network for a hospital that is in-network, that should be, at the very least, disclosed to you,” Binder said. “There should be alternatives for you so you're not forced to use a provider who's not in your network, when you have, in all good faith, gone to a hospital that's in-network.”

There is a lot of progress around this on Capitol Hill, Binder acknowledged. The Leapfrog Group hopes that some of the bills that would address surprise billing can move forward, but Binder said organizational efforts against surprise billing are still top of mind.

“Those shenanigans have also been going on for a long time,” she said. “Ultimately, we'd like to see where hospitals just don't allow it. A provider who does not accept the same health insurance as the hospital should not be allowed to practice within a hospital. Now, we get it, that's hard to get to, that's difficult. Again, we understand that, but at the same time, we're fighting for the patient, and so we want everyone to fight with us.”

Binder said she wants every healthcare organization, regardless of size, rurality, or patient panel, to join Leapfrog in this fight. Of course, some organizations have more resources and capital to move health equity and ethical billing forward, but Binder doesn’t see that as an excuse for smaller hospitals. After all, it’s not as though health disparities don’t exist in smaller hospital settings; health equity is important for every organization to close those gaps.

“The fact that it may be a small ASC or a small hospital is not an excuse. A small hospital still has, usually, hundreds, if not thousands of people entrusting their lives to its care every single day,” Binder pointed out.

And as a result, Binder and The Leapfrog Group maintain that these organizations need to be part of the industry fight for health equity. Part of pursuing hospital quality and patient safety is assuring health equity, and Binder said organizations of all sizes need to make this part of their jobs.

“It's going to be important for them to figure out how to do it,” she concluded. “We recognize it's not going to be easy, and we're looking for examples of who's done it best, but still there's no excuse for it. We're not going to be excusing anyone, nobody. I don't care how small a hospital you are. You're not excused. This is a critical area of need in healthcare.”