How value-based care enhances equity, inclusion, and diversity

Nkem Chukwumerije, MD, MPH, FACP, Executive Sponsor for Equity, Inclusion, and Diversity, Permanente Medical Groups; President and Executive Medical Director, The Southeast Permanente Medical Group

Recent years have seen negative reactions and pushback against equity, inclusion, and diversity (EID) initiatives. Critics contend that such programs benefit some people at the expense of others. But inclusion is about ensuring everyone’s ideas are included in the conversation. This is especially important in health care. In fact, studies show that EID initiatives in health care lead to improved care and better patient outcomes. 

At Kaiser Permanente, inclusion in health care means every patient has a voice in their care. This care experience is person-centered, compassionate, evidence-based, culturally responsive, team-delivered, and physician-led, which reflects our value-based care model.  Ultimately, it’s about emphasizing the physical, mental, and social well-being of all patients and communities we serve. That’s inclusive health care.

An intentional and proactive approach to inclusive care

Equity, inclusion, and diversity are often discussed as a single abstract concept. But in truth they are each distinct practices that interrelate and contribute to one another, and are valuable to understand on their own. This nuance is summed up well in a quote by Vernā Myers: “Diversity is being invited to the party. Inclusion is being asked to dance.”

In other words, health care organizations must go beyond merely seeking diverse backgrounds and perspectives from their teams. They need to create an inclusive environment where everyone feels secure sharing their ideas, concerns, and identities. At Kaiser Permanente, this means taking deliberate and proactive steps towards inclusive health care.

Being intentional is vital because ultimately, there is no way that you can deliver on health equity without being inclusive in your design and thinking, from clinical interventions that reduce health disparities to professional development programs that raise awareness.

Related health equity story: “Dr. Koh on advancing health equity, culturally competent care”

Programs designed to support specific groups of people benefit everyone

Designing health care systems and interventions requires taking the people you serve into account, especially vulnerable populations which traditionally may have been excluded. It also means considering social determinants of health, which can affect health in powerful ways. These include economic stability, education access and quality, health care access and quality, and social and community context. 

For nearly 80 years, our value-based care model and culture of medical excellence has addressed the root causes of health disparities. For example, a study featured in The New England Journal of Medicine revealed that ten years of intensified colorectal cancer screening using fecal immunochemical tests successfully eradicated disparities between Black and white adults in Kaiser Permanente Northern California. Additionally, organized screening improves colorectal cancer outcomes for all our members. 

Another example of intentional and inclusive design supported by our value-based care model is the Cocoon Pregnancy Care Program. A diverse group of Permanente physicians, nurses, and midwife leaders, as well as multiple specialty departments, collaborated to create an integrated maternity care program aimed at improving the quality of care mothers receive before, during, and after pregnancy. 

One of the problems the program sought to address is the high maternal mortality rate suffered by Black women who are three times more likely to die from pregnancy-related causes than white women. The program looked for ways to mitigate underlying access issues and chronic health conditions, as well as the socioeconomic and structural racism issues that burden many women. One tactic the Cocoon Pregnancy Care Program used to tackle the problem is a remote monitoring system that tracks blood pressure trends in patients who were about to give birth or had done so recently. Patients enrolled in the system were 43% more likely to have normal blood pressure postpartum. 

Related social determinants of health story: “Advancing health equity through improved perinatal care”

A moral and business imperative to do right 

Initiatives like advanced screening for colorectal cancer and the Cocoon Pregnancy Care Program demonstrate the benefits of an inclusive approach to health care. Like diagnosing and treating patients, it starts with having a clear understanding of the problem. You need awareness of what the issues are, including health disparities, systemic racism, a lack of diversity, and an absence of proactive, intentional practices.

A crucial aspect of addressing these challenges is to define a strategic vision that incorporates EID as essential components of our work and critical factors for achieving improved health care results. We can hold leadership accountable in these areas in multiple ways: 

• Set clear goals and expectations for EID commitments 
• Align EID initiatives and consultation with business priorities 
• Engage employees in the process
• Use data to measure progress  

Pursuing equity and inclusion are not just moral imperatives but also business imperatives, as interventions that support individual groups lead to insights that benefit all patients. Studies show that inclusive decision-making helps deliver change faster and creates better performance. In health care, making sure everyone is invited to the table and included in the conversation and decision-making helps fulfill our mission of delivering total health care to all of our patients.