Health Equity Decision-making: A Q&A With Dr N. Benjamin Fredrick

There is a difference between default decision-making and equitable decision-making that is important for people from disadvantaged populations, explained N. Benjamin Fredrick, MD, of Penn State Hershey Medical Center and Penn State University College of Medicine, who participated in a session at the 2023 Health Equity Summit titled, "Health Equity Decision Making."

Fredrick speaks with The American Journal of Managed Care^® (AJMC^®) on key themes of his session at the Summit, as well as key areas of research within health equity that require further investigation and how short- and long-term policies and practices should be designed to advance equity.

AJMC^®: At this year’s Health Equity Summit, you’re leading a discussion on health equity decision making. Can you first speak on some of the key themes you will be presenting during your session?

Fredrick: The main themes relate to distinguishing between default decision-making and equitable decision making, and some key principles that characterize equitable decision-making.

Default decision-making does not take into account the needs of historically disadvantaged groups. This is the common decision-making approach which generally produce solutions that work for those who are similar in important ways to the decision-makers themselves. Since historically disadvantaged groups are generally not in on the decision-making processes, these default decisions tend to produce gaps or additional barriers or burdens for socially vulnerable groups. This results in the unwitting perpetuation of disadvantage, which show up as measurable health disparities.

Several key principles of health equity decision-making are:

• Make a commitment to health equity
• Identify vulnerable groups upfront
• Design and build with vulnerable groups
• Invest in health equity, allocating resources proportionate to needs

AJMC^®: There will be a myriad of health care stakeholders attending the meeting, including payers, providers, industry, and health benefit consultants. As integration of health equity initiatives would require multidisciplinary action and aligned objectives, what do you hope each audience member gains from your session as it pertains to addressing the health inequities prevalent in their respective communities?

Fredrick: Pursuing health equity requires changes at the individual level, that of the systems and structures, and the society of each organization. Health inequities are often thought to arise through nefarious means, but inequities also arise through seemingly benign decisions that do not take into account historically vulnerable or disadvantaged populations.

The main take-home point is that pursuing health equity begins with a change in the culture of our organizations, and a willingness to critique our routine decisions in light of health equity principles.

AJMC^®: Health inequities have persisted for decades but the amount of research on their impact is limited. In identifying these community-level health inequities, what data trends are noteworthy?

Fredrick: Health inequities are not inevitable, by definition. Health inequities can be and need to be addressed. We are seeing very good work being done that is reducing health inequities in some areas, like maternal mortality in certain states. Organizations are taking data to heart and learning how to intervene in their own contexts.

We are the cusp of a revolution in data collection and analyses that is beginning to prioritize health equity in a meaningful way. Health equity work requires a complexity science approach.

AJMC^®: What are some key areas within health equity that require further investigation?

Fredrick: As more and more data are collected we are finding that the number of potential variables contributing to inequities can be dizzying. We need to cultivate a mindset that does not look for the single bullet solution, but one that embraces multivariate analysis and multisectoral solutions. Since this science is so new, we also need patience and persistence to implement interventions given the evidence before us and see what works and what does not work.

On a practical level, I think we could benefit from a scholarly vehicle, akin to MedEdPortal for medical education, that serves as a searchable and open repository for peer-reviewed health equity interventions.

AJMC^®: Initiatives aimed at addressing health inequities are largely in their infancy and the impact of these actions likely won’t be felt for generations to come. In considering the quality, cost, and access issues impacting health outcomes, how should short- and long-term policies and practices be designed to advance equity?

Fredrick: Funders and policy makers need a long-term approach to researching and implementing solutions, perhaps similar to what NASA has developed with its space travel efforts. With space travel, NASA developed a plan that has many stages in order to achieve the goal. While health equity work is not as straightforward as that, it will benefit from some ambitious goals that align the major actors.

Look to the work of the Millennium Development Goals, and now the Sustainable Development Goals for efforts to align around health and wellness initiatives on a massive, global scale. Perhaps a similar effort can occur around health inequities.

Finally, don’t dismiss small-scale efforts. Every effort toward health equity is important, if for no other reason than it is an individual’s attempt to right what is wrong, and that should encourage each one of us.

AJMC^®: What is a disparity in health care that you think doesn’t get as much attention as it should?

Fredrick: Easy: use of interpreters. So much of high-quality health care is based on effective communication. Failure to use an interpreter should be a never-event in health care. Interpreters often also serve as cultural liaisons which, again, is an important form of interpersonal communication that can generate errors, mistakes, missteps, and ultimately subpar care, which is then measured on a population level as a disparity.

AJMC^®: Was there anything else you want to add from your session at the 2023 Health Equity Summit?

Fredrick: The topic of health equity is quite broad. A framework that has helped me get my head around both the contributors to inequities and to the intervention levels is Self, Systems, Structures, and Society. Each level interacts with and influences the others, similar to the socioecological model. When people talk about health equity I find myself mapping their comments along this spectrum and that helps me from becoming too dizzy.