Healthcare inequities – the gaps in how different people experience the healthcare system based on their ethnicity, income, geographic location and other factors – are increasingly well understood. But less clear are real-world solutions to closing these gaps, and even what role different organizations should take in leading the change.
In the January 2023 issue of the Harvard Business Review, Accolade chief medical officer Dr. Shantanu Nundy and his co-authors make the case for why employers should make closing health equity gaps in their workforces a high priority.
We caught up with Dr. Nundy to dive deeper on some of the points in the article, including how employers can work with their health plans to close health equity gaps and what actions they can take with benefits and beyond to improve health equity.
Why should employers be concerned about health equity gaps in their workforce? What aspects of business are impacted by these health equity gaps?
Gaps in health equity impact employers on multiple levels. The first is retaining talent. We know diverse teams are more productive than non-diverse teams. We know one of the main reasons people leave jobs is because of their health. And we know that healthcare is even more complex for people in marginalized communities. Therefore, if you want to lead a diverse, productive organization, you must pay attention to health equity.
Beyond this, if you want to be a healthy organization, you must work on health equity. If people aren’t healthy, they miss more work, and they’re likely to be less productive when they are at work.
In the U.S., self-insured employers are responsible for their employees’ healthcare costs. Health inequities mean these business costs for employers are often higher than they need to be, because people’s needs are not being addressed effectively – resulting in higher costs and unnecessary procedures.
What are some steps employers can take to close health equity gaps for their employees?
Fortunately, this isn’t a new or unfamiliar challenge for employers anymore. In 2023, many HR and business leaders have heard about health inequities, and they understand that where you live, where you work, what your salary is, whether you have access to childcare – those things impact your health.
But the next part of that conversation is: who influences where you work, where you live, what your salary is, what job opportunities or childcare you have access to? In many cases, that’s your employer. There’s a tendency for some people to look at this issue and say “Oh, now you want employers to also do this?” But the fact is, employers already have a lot to do with this issue.
Here's a simple example: most people get their health insurance from their employers. A very simple thing employers can do is to review what percent of people’s after-tax income is going to healthcare premiums. If everyone in your employee population is paying the same absolute dollar amount towards their premium, then the people who are being paid the least are paying the greatest percentage of their income toward healthcare. Meanwhile, your highest paid employees are paying the least for healthcare, on a percentage basis.
One approach that some employers take to improve health equity is to graduate their healthcare contributions so that no employee pays more than 10% of their take home pay toward healthcare premiums. In our Harvard Business Review article, my co-authors and I identify benefit and plan design as a place where employers can impact health equity among their employees.
Can you go into that a little more? What role do health plans play in addressing health equity? How can employers nudge plans in the right direction on this front?
Plans have several functions, from maintaining a network of doctors and handling claims and billing to offering member services and clinical programs. Too often, employers look at health plans as monolithic, but they’re not. Employers can look at their carrier’s services individually and ask, ‘Where is the health equity opportunity for us?’
For example, your health plan determines what doctors and hospitals are in-network for your employees. Something that one of our customers did was look at their network and say ‘We only want to include hospitals that are high-quality.’
And that instinct makes a lot of sense! But when they looked at the issue through a health equity lens, they realized they were about to cut out a hospital on the South Side of Chicago that, if they had cut it out, their employees who lived in that area would not have an in-network hospital in a convenient radius of their home. That’s an example of applying a health equity lens to network design.
Or take something like member services, which Accolade does. We know that having a diverse frontline care team can make a difference – that’s demonstrated in research by Lisa Cooper, my co-author, who showed that when doctors and patients have similar race and ethnicity, quality of care improves.  So employers can, and should, be asking their health plans things like ‘What is the makeup of your member services team, and does it represent the diversity of our members and their families?” And that should factor into whether a health plan is the right one for your organization, or whether you would be better off carving out that function to another organization.
Talk about some of the benefits that are outside the realm of what we think of as traditional healthcare but can still be impactful in terms of closing health equity gaps.
Employers typically provide people with health insurance, but they also may provide their employees with a 401k, transportation benefits, childcare assistance, legal support and all sorts of other benefits. From a health equity perspective, those other benefits help address some of the root causes that prevent people from being able to have optimal healthcare outcomes. For example, if you have childcare, you are more likely to make and keep a doctor’s appointment, because someone is watching your kid, so you can be at the doctor’s office.
What role does technology play in closing these gaps and ending these disparities?
Technology has a role to play from multiple different lenses. One is the role telemedicine can play in expanding healthcare access and letting people connect with a much broader and more diverse array of doctors than may be available where they live. For example, if you’re a person who identifies as LGBTQ in a small rural community without many providers trained in LGBTQ needs, you may not feel comfortable getting care in that area. But when you can virtually access doctors across the whole state, or the whole country, you’re much more likely to find a doctor who meets your needs. That matters a lot.
Technology, when it’s used well, should also make the whole process of accessing care a lot simpler. Often, my patients don’t refill a prescription simply because there are so many hurdles on the way. By sending patients a text message that says ‘Press 1 to get your medication refilled,’ we can create an experience that makes it much more likely for patients to access to their medication.
Are there companies that strike you as doing the right things and being on the right path in terms of advancing health equity?
United Airlines is doing some impressive work on this front. One example is how they are using employee-run Business Resource Groups that amplify the voices of employees to co-design health equity solutions they’re rolling out. This philosophy of ‘nothing about us, without us’ is critical when it comes to closing health equity gaps.
If you could give human resources leaders one piece of advice about how to advance health equity in their organization, what would that be?
Define the business case for health equity. Health inequity is a serious challenge and there are multiple initiatives HR leaders will need to invest in over multiple years to meaningfully impact it. To make those kinds of sustained investments, you have to define the business case so that the rest of the company sees health equity not only as a nice-to-have for their employees, but also critical to the success of the business.