Rae Woods:
From Advisory Board, we are bringing you a radio advisory. My name is Rachel Woods. You can call me Rae. We are back to talk about my favorite topic in healthcare, which is health equity. I spend a lot of time talking about racism and equity on this podcast, but on this episode, I want to make sure we're going a level deeper and providing listeners from every corner of the industry with action steps that they can take back to build a more equitable future. To do that, I brought two folks to Radio Advisory. Health equity expert, Darby Sullivan, and industry expert, Solomon Banjo. Hey Darby. Hey Solomon.

Darby Sullivan:
Hi Rae.

Solomon Banjo:
Hey Rae.

Rae Woods:
Back once again to talk about my favorite topic, perhaps your favorite topic, which is health equity.

Solomon Banjo:
Certainly I think the most consequential topic that I get to research on a day to day basis.

Rae Woods:
Darby, we know this is your favorite topic.

Darby Sullivan:
Yes. I love to be here talking with you, Rae, and Sullivan about this.

Rae Woods:
Well, before we get into any of the details about what aspect of health equity we're going to be talking about, I always like to ground these conversations in what do we even mean when we say health equity? Darby define for me what is an equitable organization?

Darby Sullivan:
Yes. It's a very big question that we've been thinking about a lot because we realized that when we talked about health equity at the Advisory Board, we never really defined exactly sort of the perfect end state. And so now when we talk about what an organization has to do to become equitable, we think about actions that they take across three different pillars: the workforce, patient outcomes and the community. So that means that no matter what position you're sitting in, in the industry, you're trying to create a more diverse workforce with an inclusive culture. You are aiming to create equitable practices for your workforce. You are aiming to create products and services that improve patient outcomes. And you're also trying to address the things like the social determinants of health and their root causes.

Rae Woods:
So if that's what we are aiming for, I'm hoping that we can spend this conversation talking about how we actually do it. And maybe why organizations have struggled with this to date. So at a high level, how do we create a more equitable organization across healthcare not specific to providers.

Darby Sullivan:
Yep. And so this is very, very high level, but when we think about how to actually achieve equity across those three pillars, workforce, patient outcomes, and the community, we think about organizations that are making sure they're dedicating specific resources to address the biggest gaps across those pillars. So sometimes that looks like a dedicated team with a C-suite representation. And at the same time, we also need organizations to say, we are going to embed equity into every single thing that we do. So from your quality improvement team to your rev cycle team, and think about how our actions in every single thing that we do, either mitigates or exacerbates disparities.

Rae Woods:
And my guess is that second part is what's harder. How do we actually embed equity into the DNA of an organization, into everything an organization does? Admittedly, we've talked about that on this podcast before from the provider lens. We did an episode with the CEO of RWJBarnabas who was on his own journey to embed equity into all aspects of their strategic plan. But Solomon, I'm guessing this is not just something that we want providers to do.

Solomon Banjo:
Absolutely. I think at its core, equity is a health problem, not just a healthcare problem. So it requires all stakeholders across the ecosystem to really be engaged as well as obviously policy makers, because of just the breadth and depth, and again, as Darby touched on, the unmet social needs element as well that no one organization or organization type can obviously meet.

Rae Woods:
If no single organization can achieve or maybe advance is the better term, health equity today, maybe we should unpack why that is so difficult because in this moment, over the last several months, gosh, I can't think of any organization that hasn't said I am for health equity, or I would like to be an anti-racist organization, or I want to combat inequities as they manifest in my business. But why is it so hard for those different businesses to actually work together?

Solomon Banjo:
I think this is often a question we encounter at the Advisory Board where the challenges we're helping our members meet are things that they've known for a long while that they need to tackle. And so what's getting in their way, and this is where we do things like root cause analyses to really try and pinpoint in the simplest clearest forms, what are the barriers preventing progress despite the desire of various stakeholders to tackle it? And I think this is particularly necessary and relevant when thinking about health equity.

Rae Woods:
And this is what you and Darby did. You actually sat down and said here's this problem that is multilayered, it is complex. Like you said, Solomon, this is probably the most difficult problem in the world. Maybe even in healthcare. So let's unpack why it is that we're not able to advance equity. What did the two of you find when you did this root cause exercise?

Darby Sullivan:
After a few hours, sort of putting our heads down to brainstorm all of the different reasons why we see organizations struggling to embed equity into everything that they do, we landed on sort of two major categories or two major reasons. So the first being that a lot of folks are just intimidated by just how enormous this problem is, particularly because it requires us to do things that we have not done before, or we don't actually exactly know what our next steps are.

Rae Woods:
Hence me saying, this is perhaps the biggest challenge, and I'm trying not to be hyperbolic when I say that.

Darby Sullivan:
And folks are also afraid of what happens if we try and fail? What are the sort of the downsides of that? So that's sort of one category. The other category is that transparently, a lot of organizations in our industry function well enough in the status quo that they don't feel that they need to make a change. So the penalties aren't big enough or the benefits aren't big enough to really make me change the way I do business. So I can get away with either kind of ignoring the problem or investing in kind of small one off solutions that can be helpful to a few people, but don't get at the root causes.

Solomon Banjo:
And to build on something Darby said about the enormity of the problem, I think, another challenge and that fear of failure is, and we push our members to actually state your equity ambition, actually put out there what are you trying to accomplish? But when you think about news coverage of failures to achieve equity or areas where disparities are uncovered, there's a lot of social pressure for people to not put a stake in the ground being because they're afraid that if they try and fail, all there's going to be focus on is the failure. And that's the kind of press that no one really wants to have.

Rae Woods:
Or that's why they use these [inaudible 00:07:49] terms. I have said on this podcast before, and I will say it again, that I am immensely frustrated anytime I hear a healthcare organization put out some mission statement around equity that basically says we exist to serve patients. Duh. Nobody would say that we don't exist to provide the best quality patient care or to support the upstream interventions that will ultimately make it down to real people. Nobody's going to say that they're against that. But what you're saying Solomon, is actually making real progress requires being a little bit more specific about what you're going to do, even if it's outside of your core competencies and dealing with the fact that that might go against what's made your business successful, I'm going to use the word profitable to date.

Solomon Banjo:
No, absolutely. I think as we think about most systems, they get the results that they're sort of designed for. And for a lot of people, the current system is working quite effectively and so potentially changing this can be fraught.

Rae Woods:
So the two of you and your team sat down and you did this root cause exercise. And you thought through all of these specific challenges and at a simple, simple level, rolled them up to these two buckets. But I have to say, they're also enormous challenges on their own. So I want to break them down a little bit. And I want to start with the first thing you mentioned Darby, which is organizations. Aren't able to actually embed equity into every aspect of their strategic plan because it's just not something that they do. And that's where I hear most folks say, we need a community partner. Is that the right answer here?

Darby Sullivan:
It is a part of the answer, but it cannot be the entire answer. So I want to like emphasize community partners are completely a non-negotiable in this work. You can't be successful unless you're working with them because they have things like deep community trust. And because they offer some of the services that we don't traditionally do, however we can't stop there. And I think a lot of folks tend to stop with community partners because we are sort of hesitant to work within our own industry where we might have competitors. Or we might have folks that we traditionally are kind of like frenemies with. And it's tough to say, hey, we're going to set aside our differences or our sort of competitive advantages here because we want to work together towards something bigger.

Rae Woods:
Yeah, that's so right. I hear organizations say, we're working with a local food bank, we're working with churches, we're working with schools, but I don't actually hear them say, we're working with the competing health system, or we're working with the payer, or we're working with that drug company. Solomon, you kind of represent the industry perspective. Do you have an example of organizations coming together to solve some of these problems?

Solomon Banjo:
Yes. And I think one example that easily comes to mind is the work my team has been doing around clinical trial diversity and access because this is an area where there's a tremendous amount of interest, tremendous amount of energy, [inaudible 00:11:07] a recognition is we did our research that people are talking past each other or maybe not even talking, as you mentioned, the frenemies Darby.

Solomon Banjo:
I love the new term co-opetition. So how do you compete and cooperate? And so we hosted a session to bring together sponsors, payers, clinicians, community based organizations, to say, and these are the things we know we need to make progress on, how does that challenge our existing roles? How does that challenge our existing business model models? And can we actually create a safe space for people to say the thing that has perhaps been at the back of their head? But hey, I really need you to view me differently when it comes to how you partner with me, because it feels really extractive in one way. And there's a lot you could do to help build my capacity or stop trying to become a trusted party, you need to work with trust brokers and I can be that for you and really just creating that space. And it was just a really helpful conversation that has spurred a lot of desire for subsequent partnership.

Rae Woods:
I love that this is something that Advisory Board can do. We can bring together stakeholders from across the industry and create the environment and the space for them to tackle difficult decisions with their so-called frenemies. But I wonder if you can give some advice to our listeners for how they can create that same kind of safe, cooperative environment in their home organizations.

Solomon Banjo:
I think part of it stems from a piece of advice progressive organizations, when it comes to [inaudible 00:12:45] inequity have been using in terms of thinking of who's missing from this conversation? I think that could be really helpful from an internal lens, but I also think it's helpful externally. We're trying to make progress on this issue. We're trying to address unmet social needs. Who's missing? Who else impacts and touches on this and how can we create that dialogue? I think the first step honestly, is just the willingness to meet and have that conversation around this is an area where we have some shared interests. What would it take for us to actually make progress here? And I don't see a lot of organizations taking that first step.

Rae Woods:
Shared interest is one thing and it's a lot easier than shared incentives.

Darby Sullivan:
Yep.

Rae Woods:
We know that one of the reasons why this is such a complicated challenge in healthcare is because there are often outright competing incentives to make real fundamental progress on health equity. And that's got to be one of the biggest reasons why these different parts of the industry or these frenemies aren't actually working together. I guess my question is how is it to change and perfectly align those incentives before we can even make progress?

Darby Sullivan:
I agree that I think ultimately it all boils down to the fact that our industry is not incentivized to address health equity fundamentally like you mentioned. But I do think it would be a mistake to sort of just wait and hope that our incentives will become perfectly aligned from some major bipartisan legislation that I don't think is coming anytime soon.

Rae Woods:
No, we would be waiting forever.

Darby Sullivan:
Yeah. So that could be our goal, but to do nothing until we get there, I think would be a waste. So two things I think folks should start to think about in the meantime is number one, how are you making sure your own house is in order first? Meaning are you doing what you need to be doing internally to prove that you're going to be a good, transparent, trusting partner? Are you going to be full and be able to meet your partner's needs? Do you have infrastructure for this work so that it doesn't just sort of fade away when your number one champion leaves? And then in terms of how you pick the perfect partner, I don't think you have to wait for perfect incentive alignment. You just both have to be willing to make progress and hold each other accountable along the way.

Rae Woods:
I know I just said that incentive alignment is important, even if we're not going to wait for the perfect moment. But there's this other argument that the incentives and the financial kind of carrot can't be the reason why we are pursuing equity. What do you think about that?

Darby Sullivan:
Yeah, those ideas sort of exist on either end of the spectrum, which is on the one hand, it's deeply offensive to say we have to prove that this is good for our business in order for us to care about health equity. So that's on one end of the spectrum. On the other end, we can't just treat it like charity, which is where I think some folks sort of tend to go where they say no matter what we do in this space, because it's the right thing to do, it's beneficial. We think about it sort of, kind of in the middle, whereas you need to acknowledge that this is absolutely a moral imperative and part of what we need to be doing as a healthcare industry. And also we have to bring strategic rigor to the work that we do and realize that there are other business priorities beyond just a strict financial ROI that makes this work worth it.

Rae Woods:
So what are some examples beyond financial ROI that can ground organizations and strategic rigor while balancing this moral and business imperative?

Darby Sullivan:
Yeah. So it's thinking about are our investments to advance equity building to an authentic market facing brand where we're actually living the values that we say? Is this improving our employee value proposition? Which we know is really important today in a tight labor market. It's also about the consumer experience. So how are you improving your products or your services in a way that builds loyalty? And those are sort of the broader cross industry business priorities, but there's also for providers to be ready for downside risk if and when it becomes a little bit more mandatory as we're watching from CMS. This is the kind of work that gets you ready for that.

Solomon Banjo:
And to go back to the clinical trials example, because I agree with what Darby said. Often when talking about the value there people point to, oh, it can help with patient recruitment. Oh it obviously makes the science better because we're able to see differential impacts, risk rewards, but there's also, I think an element of needing to take a more expansive viewpoint to where value and how values realize. For example, being more equitable in how you run clinical trials, it does allow you to engender trust, it does allow you to understand potential pushbacks and just how people view the messaging. It also helps you convince clinicians or show them data on how this can actually help them interact with the diverse patient populations they interact with. And so it has a host of benefits that we have been guilty of as an industry of not highlighting when we talk about all the benefit there. And I'm sure that applies to other equity imperatives where we are just not actually taking that step back to think of other ways in which it actually supports our various strategic objectives.

Rae Woods:
I love this example because I feel like I spend a lot of time trying to push folks to think about downstream consequences. And I'm using the word consequence because I mean the negative implications of what we might get wrong if we're not grounding ourself in equity. But Solomon you're bringing up a really good point that there's also positive downstream implications if we just think beyond how much money can I make on this in the moment. And that's where we really need to bring that strategic rigor that will allow us to make fundamental changes and not just around the edges.

Solomon Banjo:
Totally agree.

Rae Woods:
Darby, you started off by talking about these three pillars of equity and how they all intersect with one another. You can't just think about patient outcomes or the workforce or the community because they all kind of overlap. And I imagine that's a similar way that we should think about different parts of the industry. It can be easy to think about some of these things as just a provider challenge or just a pharma challenge. I wonder if you can give me an example of different parts of the ecosystem that are coming together to solve a similar challenge.

Darby Sullivan:
Yeah. I love how you tied those things together. Some of the things that we're watching and I guess the example that I'm most excited about actually comes to of the health plan world. So we're starting to speak with some folks who are weaving equity into their quality and performance scorecards for their providers so that they can start tracking, just like they track other quality measures, is this organization providing equitable care? And then the idea is eventually that could be tied to reimbursement down the line so that you are building that incentive for providers, sort of health plans using their leverage and their position in the industry to push providers forward.

Rae Woods:
I love that example Darby. I think I know the organization that you are thinking of and it is definitely one to emulate. But I will be the first to admit that I don't know that anyone has perfectly figured this out yet. So maybe this is a moment for me to just talk to our audience and say, if you are doing this work, if you are sitting down with others from across the industry, if you are working with your frenemies and figuring out how to come together with shared accountability and shared business goals, let us know. Because frankly, we want to shout those stories from the rooftops.

Darby Sullivan:
And Rae, can I give another example of something that any organization in the industry can do?

Rae Woods:
Absolutely.

Darby Sullivan:
This is inspired by a health system, but truly any organization can say when I'm looking for suppliers or when I'm looking to work with a vendor, I'm only going to select those that commit to what's commonly known as anchor requirements. So are they serving as an anchor or helping to serve as an anchor in their community? Meaning are they hiring locally? Are they paying folks a living wage and giving adequate benefits? Are they committing to environmentally sustainable practices? No matter who you are, you can be more choosy about the partners you work with for any type of business priority or business decision.

Rae Woods:
We've been talking about why organizations need to embed equity into everything that they do. And we've started to get at how that actually works in practice, but what's the risk here if organizations fail at this? What's the risk if we don't actually embed equity into the DNA of our organizations?

Darby Sullivan:
I think that there are two risks and this is something that we uncovered in our root cause analysis exercise, which is on the one hand, we might make smaller, incremental progress, but we lose our momentum because we're not seeing the large scale change that people are demanding right now. And on the other hand, we could actually exacerbate the very inequities that we are trying to fight against because ultimately if we put a lot of money and time and resources into this and we fail, our leaders could look back and say, hey, that wasn't worth it. This is impossible for us to change so we shouldn't try. And we've actually made the problem worse.

Solomon Banjo:
And I want to build on what Darby just said, because when you were talking Rae, about the challenges I see my mind went in the future. If we don't get this right, because when you think of all the transformational innovations that are starting to gain traction, telehealth, precision medicine, artificial augmented intelligence, the real risk that those systems can dramatically exacerbate disparities to Darby's point is one of the things that keeps me and my team up at night. And I think that is part of why it's so imperative to start grappling with this and to keep grappling with this because these challenges could get far worse as the healthier ecosystem evolves.

Rae Woods:
Which brings me to my last question. The health equity challenge is going to be the most difficult thing that we try to tackle as an ecosystem. And it can be hard to think about where organizations should begin. So I want you to tell me what's the one takeaway or the one action item that you want to push our listeners to focus on right now?

Solomon Banjo:
I'll stick with that theme of evolution because I think successful businesses evolve. Like Facebook did not set out to become an ad giant when it was initially founded. And I bring this up because my action item/question for our audience is how is pursuing your health equity ambition actually causing you and your organization to evolve, to change, in order to create that more equitable system that we know we need? If you look at what you're doing and you're not really seeing evolution, not being challenged, I would argue that you probably need to take a second look at what you're trying to accomplish and how you're trying to accomplish it.

Rae Woods:
Darby, what about you?

Darby Sullivan:
My final thought is a little bit more granular or tactical, which is tomorrow, can you go and say, I'm going to go and embed equity into my performance evaluation for every single part of my workforce, from entry level folks all the way up to the C-suite? So are folks going to be actually financially accountable for change on an individual level? And on top of that, will I commit to being accountable to progress, including successes, but also including where we might fall short today?

Rae Woods:
Well, Darby, Solomon, thanks for coming back on Radio Advisory.

Darby Sullivan:
Thanks for having us.

Solomon Banjo:
Always a pleasure Rae.

Rae Woods:
In any conversation around health equity, there is a single piece of advice that I want you to take away. To solve big challenges, we need to set our sights on big solutions. And that means we cannot do it alone. We need to make sure we're working across the industry and setting our sights, not just on big, bold changes, but we're putting the infrastructure in place to allow us to meet those goals even if it takes several years. This is a big challenge. So remember, as always, we're here to help.