WATCH: How hospitals can improve racial inclusivity

By Judith Garber | September 21, 2023

This week the Lown Institute brought together health equity experts and hospital leaders to discuss segregation in hospital markets and strategies for improving inclusivity. Watch the full recording of the event and see our key takeaways below.

Guest panelists were:

Dr. Uché Blackstock, founder of Advancing Health Equity, which partners with healthcare organizations. Her forthcoming book, Legacy: A Black Physician Reckons with Racism in Medicine, will be released in January 2024.
Dr. Selwyn Rogers, acclaimed surgeon and founding director of the University of Chicago Trauma Center. He was recently named an associate editor for the New England Journal of Medicine and serves as a member of the Lown Institute Board.
Dr. Elena Mendez-Escobar, Co-Director at the Health Equity Accelerator at Boston Medical Center, responsible for strategy.

Why hospital segregation happens

The Lown Institute’s racial inclusivity metric shows how well hospitals serve patients from communities of color in their surrounding area. We consistently find that some of the most and least racially inclusive hospitals are in the same metro areas, demonstrating patterns of segregation in American cities. (See the cities with the most segregated hospital markets on the Lown Hospitals Index website.)

More than fifty years after segregation was outlawed, we still see segregation in healthcare in similar ways that we see in education and housing. In racially diverse urban areas, some hospitals are disproportionately serving communities of color while others disproportionately serve patients from whiter and wealthier areas.

Why does this happen? Redlining and other forms of residential segregation; inequities in reimbursement rates for patients based on insurance status, which correlates with race; differences in hospital culture and staff diversity; and many other factors play a role.

“What we’re really looking at are the long-term effects of structural racism and classism.”
Dr. Vikas Saini

However, just because hospital segregation is long-standing doesn’t mean we should tolerate or normalize it, panelists said. “People expect these differences to exist, and sometimes that can paralyze us. It shouldn’t be this way,” said Dr. Mendez-Escobar.

Policy solutions for more inclusive hospitals

How do we begin to solve such a complex and entrenched problem? One of the big structural elements that perpetuate segregation is the way we pay hospitals–giving them more to care for patients with private insurance, and more to perform elective procedures rather than preventive care.

“We pay [hospitals] for doing stuff…there’s not a lot of pay in not doing stuff, and there’s even less pay in preventative things that for the most part fall into the public health realm.”
Dr. Selwyn Rogers

We’ve created a “two-tiered system,” said Dr. Mendez-Escobar. It’s not only a segregated system but it’s also unequal, as the hospitals serving more patients of color tend to have the least amount of funding, she said.

In many ways, segregated hospital markets reflect a “segregated insurance market,” said Dr. Saini. “It seems pretty obvious that if all patients meant the same revenue opportunity for everybody all the time…we’d go a huge way toward removing some of the structural impediments,” said Saini.

This can have a large impact on who can access care or feels welcome at certain hospitals. For example, Dr. Blackstock recalled working at an academic medical center where EMTs did not bring certain patients to the hospital because they were worried about getting in trouble for doing so.

But that’s just one piece of the puzzle, panelists said. Even a single-payer system wouldn’t solve the issues of structural racism that impact health access. Dr. Blackstock noted that communities that have high levels of interaction with police have greater mistrust in the health system, and therefore may not seek treatment for unmet health needs even if they have insurance. “We really have to understand the myriad of ways that systemic racism plays out,” she said.

What hospitals can do

Larger policy changes are undoubtedly needed to close racial health gaps, but there are still many things hospitals can do on an individual level to improve inclusivity and reduce disparities.

“Hospitals can’t change the past, we can’t change the present, but we can influence the future. We have to be intentional.”
Dr. Selwyn Rogers

One way to tackle upstream health outcomes is through equitable hiring decisions and investing more into communities of color. Income is one of the key social drivers of health and hospitals are often some of the largest employers in their community; the decisions hospitals make about who to hire, who they promote, and how they procure resources can have a large impact in financial security of their communities. BMC offers financial coaching to patients as one way to improve financial security as well, said Mendez-Escobar. “If you’re the economic engine, buy local,” Rogers added.

To make a difference in health disparities, hospitals have to see equity as a quality issue, panelists said. That means tracking outcomes metrics across racial, ethnic, and socioeconomic groups, identifying disparities, and evaluating the impact of interventions. For example, at BMC there was a large racial disparity in how long it took patients to undergo a cesarean section after they had decided to have the surgery. A longer time before surgery creates more opportunity for complications. By standardizing a goal of 60 minutes or less for all patients, outcomes improved for patients of all races, but especially helped Black patients.

“This is not rocket science. This is really about centering the communities that your hospital has a mission to serve.”
Dr. Uché Blackstock

Additionally, involving community members directly in hospital decision-making is key. At UChicago, they have a community action council, of about 20 representatives from the community, who provide guidance and advice to hospital leaders. Dr. Blackstock agreed that hospitals can “look more at community governance models where community members, employees, even patients are involved in helping develop health equity metrics to ensure transparency.”

For much more on this topic, watch the full video of the event and see the racial inclusivity results from the Lown Hospitals Index.

This analysis of California’s state budget from 2007 to 2018 finds that to ensure the long-term health of the state, California needs to eliminate health care waste and direct the savings toward increased funding for programs that improve community conditions—like public education, public health, housing assistance, food assistance, and income support.