Health equity: Activating meaningful change

The COVID-19 pandemic has highlighted longstanding health and social inequities in healthcare and raised the urgent question of how health equity can be achieved.

Many organizations in both the public and private sector have responded to the COVID-19 pandemic with efforts to address health equity issues. One such organization is Healthfirst, New York’s largest not-for-profit insurer, which provides plans across Medicaid, Medicare Advantage, long-term care, qualified health plans, and individual and small-group plans. Healthfirst currently serves 1.7 million members, who speak 70 different languages, across these products. The company is sharing its evidence-based approach to closing health equity gaps through Healthfirst ADVANCE, a collaboration between Healthfirst and its 15 founding hospital systems, local providers, and community partners, which champions the health needs of New York’s marginalized populations, who have been adversely affected by disparities in health and social determinants. This collaboration also serves as a call to action for other health insurers to join the movement to advance health equity and to implement programs that help address some of the long-standing gaps in the healthcare system that have been further exposed by the pandemic.

In this episode of the McKinsey on Healthcare podcast, McKinsey partner Carlos Pardo Martin talks with Errol Pierre, senior vice president of state programs at Healthfirst, about working with diverse communities, how to go all in on health equity, and the urgent need to ensure that vulnerable populations receive the care they need. An edited transcript of their conversation follows.

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Health equity: Activating meaningful change

McKinsey: New York is arguably one of the most diverse cities in the world. How does that create challenges or opportunities when managing the health of this community?

Errol Pierre: I see it all as an opportunity because it allows us to bring together a diverse group of people and share best practices. I think that’s the key to diversity—the ability to leverage people who have a different lens looking at the same problem. This makes it possible to come up with different ideas and strategies and then develop best practices. If something works with one population, sometimes we try it with another while also making changes based on the specific needs of that population. We partner closely with key stakeholders in communities, and working with them allows us credibility with those populations and the ability to move the needle.

McKinsey: How did developing a bespoke model for each of your communities work during the pandemic?

Errol Pierre: Healthfirst serves some of the most vulnerable and ethnically diverse patients in New York City. Due to serving these populations, we quickly saw the disproportionate impact of the pandemic on Black and Brown communities. Our Medical Economics team was able to work closely with our chief information officer and our chief analytics officer to create a dashboard that provided us with much-needed transparency about where COVID-19 admits were occurring at their highest. With this visibility, we were able to know where to put our resources into play and partner with community physicians who were trusted in those communities to put in interventions. One example is our partnership with Somos, who is one of the largest physician groups in New York State, thus curating culturally competent solutions for the members we served.

McKinsey: Can you talk a little more broadly about how you have engaged members during these difficult pandemic years?

Errol Pierre: When COVID-19 hit in March 2020, the result was a tremendous drop in the utilization rate for our community physicians. Therefore, we knew that the only way to continue access to care was through telehealth. We made sure that all our 1.7 million members, if they had a [cell] phone, were able to access telehealth services.

So that was one big push. Another was from our quality standpoint—our physicians were unable to get members to come to their doctors’ offices due to social distancing. We modified the quality programs, mailing items directly to homes where possible. For example, a colorectal screening was carried out through Cologuard instead of at the doctor’s office. 1

We also worked with our pharmacy team and different partners in our pharmacy network to ensure that members did not have to go to the pharmacy to get their prescriptions if they were on chronic medication; instead it would be delivered to their home. We created a directory where you could look up pharmacies that delivered.

These were all developments that we rolled out at the height of COVID-19 to make sure our patients were taken care of, even if they couldn’t physically see a doctor.

McKinsey: What other activities have you undertaken to support and collaborate with community organizations?

Errol Pierre: During the pandemic, we worked with an organization called NowPow that has a digital online directory for social services and social determinants that impact health. We not only worked with NowPow to update the list so everything in their online directory was updated but we also tried to identify and bridge possible gaps. For example, we identified food deserts in the communities that we serve and then worked with NowPow to find community-based support organizations in this area to add to the NowPow directory.

McKinsey: How do you engage members who might not be digitally native or might not have access to stable broadband?

Errol Pierre: Our philosophy is digital first. However, digital first does not mean digital only. While we’re pursuing the digital approach, we always have an avenue for in-person partnership available. For example, our marketing team used text messaging to inform members where vaccination sites were and to ask members if they wanted their vaccine. We then scheduled appointments on their behalf through digital means.

However, in terms of nondigital, we were consistently present in communities, providing education with different partnerships and different providers. For example, we gave COVID-19-education seminars, donated masks at food pantries, and donated personal protective equipment [PPE] in these communities. So our digital approach is digital first, never digital only.

The other option was hybrid—partly in person and partly digital. For example, if you attended the community office in person, we still offered a paperless approach, such as taking a photo of a document and texting it to our representative who would then upload it to our system. Even in person, there was still the option to use digital tools.

McKinsey: How did you use data and analytics to help inform which communities to support and further understand their needs?

Errol Pierre: There are different data sets that look at social risk. It’s not a predictive model, instead it’s based on the zip code, language spoken, census tract data, et cetera. It tells you a social-index score to identify who is more vulnerable than others, which we can then back up with our internal and anecdotal information from the field. From this, we’re able to segment our population based on this data.

This gives us insights such as if we enroll a member from a particular neighborhood, we can identify where there’s a high likelihood of a higher disease burden. If there’s a higher likelihood that this member is going to need care management, we’re proactively engaged early on as they enroll, thus more able to help. So we’re getting better and better at using analytics to be proactive in our care management approach and using data to better serve our members.

McKinsey: How are you embedded within communities and able to understand what their perceptions and beliefs are toward healthcare?

Errol Pierre: One of our tenets of health equity is the diversity of our employees, which we see as a strength. We aim to hire from the communities we serve—they look like the members they serve or speak the language—there’s a trust factor there. We do the same thing with nurses, trying our best to make sure that nurses match the populations they serve—again, building trust and allowing us to have an ear to the ground on what’s happening.

One of our tenets of health equity is the diversity of our employees, which we see as a strength. We aim to hire from the communities we serve.

So being embedded is a staple to our success—we want to be hyperlocal. Those are the words we use, and we also have a community engagement team whose sole purpose is to make sure there is engagement with the key community leaders and stakeholders, delivering back to us on-the-ground feedback, et cetera. We’re collaborative with our communities to make sure that we can advance the health outcomes for these populations.

McKinsey: You talked about health risks, value-based programs, and the close collaboration with your hospital systems in the city. Can you talk about how this collaboration translates into supporting health equity?

Errol Pierre: Our quality program is arranged so that physicians receive incentives based on the quality measures they reach. An example of a quality measure could be mammograms for people of a certain age. The denominator would be the number of people assigned to the physicians, and the numerator would be the goal of achieving a 95 percent participation rate out of those who are eligible. We think that’s also what health equity is—the motivation for every doctor to hit these goals in order to get a financial incentive.

The result is that whether it’s a Black person, a Brown person, or a person who doesn’t speak English, the physicians have to craft culturally competent ways to get those patients back into their office for a preventive-care visit. We believe our quality program addresses health equity because the physicians have to figure out who needs more support to attend. So it becomes a collaborative approach to try to find the nonresponders, which means that every member will get the care they deserve.

On the value-based-payment side, where there is a surplus arrangement, there is now a focus on high-quality care and on eliminating waste, fraud, and abuse.

McKinsey: What are some of your biggest lessons from the pandemic? And which of those interventions that we have talked about will you carry forward?

Errol Pierre: The focus on digital was a big deal. We saw behavioral-health claims increase through telehealth, we saw our members using Zoom for the first time and being more comfortable with their cell phones. I think those are things that won’t go away in the future. We want to continue to embed them into all the things we do postpandemic.

We have also realized the power of collaboration. There were different community groups, health plans, for-profit plans, et cetera, that came together in New York to help service the community who may never have collaborated in the past.

COVID-19 exacerbated the social determinants of health that impact health. I think another lesson we learned is just how important the social determinants of health are. Therefore, whatever we do in the future, we have to look through a health equity lens.

McKinsey: How is Healthfirst all in on health equity?

Errol Pierre: Healthfirst was already value-based. We were already serving the most vulnerable populations and had health equity in our DNA since inception. In 2020, our CEO ensured that health equity was going to be a corporate goal for the organization. Health equity was put at the top of the list right next to compliance. So while some companies are hiring chief health equity officers, our approach has been more collaborative, meaning we look through a lens of health equity in everything we do, and essentially everyone is an ambassador for health equity.

While some companies are hiring chief health equity officers, our approach has been more collaborative, meaning we look through a lens of health equity in everything we do.

McKinsey: How do you see the future of health equity?

Errol Pierre: Our goal now is to move from crisis to recovery. The question we’re asking ourselves is, what does health equity look like in a post-COVID-19 world? We still have huge shortages of physicians and nurses and even bigger needs when it comes to ethnic concordance. By ethnic concordance I mean matching the ethnicity of healthcare workers to that of their patients. Research shows that if patients see similarities to themselves in their physicians, this can lead to improved communication, higher adherence rates, and better healthcare outcomes.

New York City and the Department of Health proclaimed racism to be a public-health crisis. So we’re also asking ourselves, what does our industry look like after that proclamation? What structural changes can we make to unravel the decades and decades of rules that allowed health inequity to exist? We’re trying to figure out a system that promotes systemic equity. So I think the future is policies, programs, procedures, health plans, providers, and pharmaceutical companies all looking through a lens of health equity and saying that the most vulnerable populations must get the care they need.

McKinsey: What structural changes are needed to improve health equity across the industry?

Errol Pierre: First, I would start with Medicaid rates, then I would focus on the quality programs for health plans. Until rates change, we won’t be able to shrink the time it takes for a Medicaid member to see a specialist. There’s a huge difference between the reimbursement rates for Medicaid plans compared to commercial plans. What this difference translates to is a two-tiered healthcare system for members, where it can take up to three or four months for a Medicaid member to access the same doctor that potentially would take two weeks if receiving commercial rates. We think the smaller the difference between Medicaid and commercial the better the outcomes of health equity will be.

From the quality-programs perspective, we believe quality programs are an important way to get health plans, hospitals, and physicians to work together for the betterment of the members’ health outcomes. The more emphasis we put on quality programs where we’re incentivizing physicians to do what’s right for the patient, the better outcomes we’ll have for all our members.

McKinsey: What advice would you give organizations focusing on health equity today?

Errol Pierre: One piece of advice is to make health equity part of your organization’s DNA and not a separate department. Also, always check your biases, because no matter how hard you try bias will seep into your decision making. Lastly, the more diversity you have in your leadership ranks the better your health plan or organization will perform.

 

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