IHI's Leadership Alliance is challenging the health care industry to assume a far greater role in mapping out the future innovations and delivery reforms needed to achieve best health and best care in the US. Government alone cannot be the “outside in” driver of change, say the authors of a March 26, 2015, Online First Viewpoint, published in the Journal of the American Medical Association (JAMA). Dr. Patrick Courneya (pictured below) is Executive Vice President and Chief Medical Officer for Kaiser Foundation Hospitals and Kaiser Foundation Health Plan at Kaiser Permanente, a member of the IHI Leadership Alliance. He says Kaiser's work to reduce health care disparities is a case in point of what can emerge from the "inside out."
In their March 26, 2015, Online First Viewpoint piece in JAMA, Berwick et al. called upon leaders in health care to move from change imposed from the “outside in” to change led from the “inside out.” While the Affordable Care Act (ACA) has extended coverage to millions and jumpstarted some new payment and care models, the authors point out the challenge for all of us is to follow through — to leap ahead in some instances — to even more dramatically transform the way care is delivered and experienced so that the changes actually lead to improvements for patients and families. Their point is well taken, and the language of “outside in” and “inside out” got me thinking about equity in health care and the challenge of closing disparities while we strive to deliver higher quality care overall. Even as we see improvement occurring, how do we respond to the fact that we have struggled – and, in too many cases, failed – to close the gaps that exist for many populations in our care who have traditionally been on the “outside” looking “in”?
The latest statistics will sound discouragingly familiar in some ways, but there is reason to hope. The 2014 National Health Care Quality and Disparities Report, published this month by AHRQ, noted that few disparities were eliminated, with parallel gains in access and quality across groups leading to persistence of most gaps. It is gratifying that, despite this fact, the report shows that several racial and ethnic disparities in childhood immunizations and procedure related adverse events have closed. Also, as expected from the ACA, after years without improvement, the report found that the rate of those without health insurance among adults ages 18 to 64 decreased substantially during the first half of 2014 and that, through 2012, improvement occurred across a broad spectrum of access measures among children.
Additional hope comes in research published in 2015 in the Journal of Clinical Oncology. Researchers from Stanford University and the University of California, San Francisco reviewed more than 30,000 patient records in the California Cancer Registry that included patients from multiple health care providers in the state. No racial/ethnic disparities existed in survival rates among Kaiser Permanente patients who had colon cancer. The lead author concluded, the integrated Kaiser Permanente “approach to care is associated with higher levels of evidence-based medicine, improved survival and reduced colon cancer disparities gaps.” Further, a 2014 study published in The New England Journal of Medicine concluded that “disparities in risk factor control for blacks have been eliminated in the West” among Kaiser Permanente members. They noted that this accomplishment might reflect systematic efforts by Kaiser Permanente to improve control of these risk factors in the last decade.
As the AHRQ report shows, the Kaiser Permanente results are not the only examples of success in closing stubborn gaps. The report also reminds us that it’s possible to overcome the barriers that created them. The implications of knowing about the populations we serve directly and proving what is possible in quality came early to me. I started practice in 1988 in a small family medicine group in the northern suburbs of Minneapolis-St. Paul. It was a time when the growing debate over the need to use evidence to drive medical practice was reaching a critical point. It was just two years later, in March 1990 in the Journal of the American Medical Association, that David Eddy laid out the principles of evidence-based guidelines and population-level practices. Despite the controversy about “cookbook” approaches the principles ignited, within a couple of years my partners and I were digging through our patients’ paper charts compiling data that until then had been locked up in the chart room. We were trying to understand if we were as good as we liked to believe. We weren’t, and that realization had a remarkable impact on us. It was transformative to have that data on the patients we served. The principles of practicing evidence-based medicine moved from an abstraction we debated to a professional obligation we accepted.
More remarkable was the fact that our interventions made a significant difference. And that gets me to the idea of ownership. When we know what is happening with the patients we care for directly, and when we have had success in improving key measures of quality, we have to deal with the fact that we have proven what is possible. We made a difference from the inside out, and now we know we can extend the benefit to all we serve by digging even deeper into our own data and engaging the patients affected by what we find. The hopeful signs of progress on closing health care disparities prove what is possible for populations that have not enjoyed the full benefit of improvements in health care quality or have not had access to adequate health care coverage. From the “inside out,” we have an opportunity to respond to the challenge posed by Berwick to break through more of the stubborn barriers that continue to create those inequities.