Building equity into our care

Like many across St. Louis, I’ve grown more concerned about the widening gap in health care infrastructure; we’ve seen the number of beds available and care options for communities across Missouri, both in the City and in our rural communities, dwindle. 

St. Louis is not the only place where some residents have to travel outside their community to access basic healthcare needs. It mirrors a trend happening across many cities: some nonprofit hospital systems are pulling back or trimming services in economically disadvantaged communities and moving into more wealthy, healthier areas where patients cost less to care for. 

This has big implications for the future of healthcare in St. Louis – and requires real solutions both on a local and a national level to spur change. 

Compounding this issue is the increasing shortage of health care providers across Missouri, fueled in part by the COVID pandemic and the increased strain on health care workers, but also by long standing trends and burnout that for too long have come hand-in-hand with these jobs.

Unless we intentionally create models of care that are inclusive of all patient populations, we will continue seeing the most vulnerable communities left behind. The results for patients here are significant: those who finally end up in the hospital for longstanding challenges often find their outcomes are worse and their treatments are more costly than if they had received consistent preventative care in their communities. People with these kinds of cases account, by some estimates, for more than two-thirds of our national healthcare costs.

Our healthcare system should be focusing more on the people who have the most complex health situations —  not less. Seemingly small, everyday changes, like managing medications properly, getting screenings and seeing a doctor who you know and trust, can lead to better health. In my work now, that’s what we are striving for on a daily basis —  rebuilding healthcare to get people healthy and keep them that way, preventing major complications and hospital visits as much as possible. To do that, we’re bringing doctors and other providers to meet patients where they are, in their communities. 

As exciting and fulfilling as this work is, one organization alone isn’t going to solve this problem. We need real change at the federal level to incentivize great care. That means changes to Medicare that improve reporting and accounting for these social factors in quality measurement. For underserved communities long ignored by the overall healthcare system, including those in Missouri, value-based care incentivizes care in long-ignored locations. 

While value-based care models are growing on the coasts, we are also seeing a comparative lack of infrastructure for value-based care in the Midwest. For our most vulnerable, and particularly older populations, they are not thriving in high-volume fee-for-service models and need more care, but most are not set up here to do that broadly yet. 

One value-based care program – ACO REACH, is an encouraging first step. The ACO REACH program is a physician-focused structure – and is the first model in Medicare’s history requiring providers to develop and implement a robust health equity plan - taking into account those social factors that affect health. This model ties healthcare reimbursement to better health outcomes and allows for additional services like transportation, social work, mental health and community social activities, which a system based on billing for each service does not. 

In my work – I’ve seen firsthand how this approach can change a patient’s health and build trust. Many become more aware of their conditions and their capacity to manage them – and call us when small problems arise, instead of going immediately to a costly and sometimes unneeded Emergency Room. Ultimately, this approach helps them take control of their own health, and leads to better outcomes in care and in cost. 

There are a wide array of policy options on the table to consider: but they all point to a simple fact: we need to move away from the traditional, fee-for-service model that drives up health costs and encourages healthcare providers to focus on bottom lines over patients and towards a care model that puts patients, not the number of services rendered, first.

Dr. Monique Williams is the Senior Medical Director at Oak Street Health in St. Louis.