Cheryl Martin (Host): Welcome to the Health Care Executive Podcast, providing you with insightful commentary and development in the world of health care leadership. To learn more, visit ACHE.org. I'm Cheryl Martin, your host for this episode, and I'm delighted to welcome Dr. Travelle Ellis and Jess Jamison, both with Exact Sciences.

They serve as senior directors, multicultural initiatives. Exact Sciences is one of ACHE's premier corporate partners. These partners support ACHE's vision and mission to advance healthcare leadership excellence. Our topic this episode, Health Equity Across the Country. Dr. Ellis and Jessica, so glad you're on today.

Travelle Ellis, MD, PhD: Hi Cheryl, thank you.

Jessica Jamison: Thanks for having us.

Host: First, briefly describe your roles at Exact Sciences. Dr. Ellis, I'd like you to go first.

Travelle Ellis, MD, PhD: Yes, so Exact Sciences is on a mission. We're on a mission to help eradicate cancer by preventing it, detecting it earlier, and guiding personalized treatment. But our roles in leading regional multicultural initiatives is to ensure that our company, Exact Sciences, achieves that mission, providing tests and services that serve all populations.

And really, Jess and I are focused on addressing the needs of diverse populations and the systems that serve them. We both started our journey with Exact Sciences as Directors of Health Equity. Jessica led our federally qualified health center team and has done a fabulous job of increasing access to patients of all insurance types to ensure that we are meeting our goals in eradicating cancer and colorectal cancer specifically for those populations.

I sat on the medical side in building strategic partnerships with advocacy and community based organizations. Again, both of us were there to achieve equitable outcomes through partnership and we're just delighted to be on this podcast to share our expertise with ACHE members.

Host: So, how can we ensure that healthcare services are not only accessible, but also culturally competent?

Travelle Ellis, MD, PhD: So first, we need to broaden our definition of access. Oftentimes individuals think access is delivering an off the shelf solution or putting something in a patient's hand. But we know that a lot of times patients don't always have a choice in what they received or is what was put in their hand acceptable to them?

Can they read it? Is it in a format that they will use? Are they able to swallow pills? Is it compromising to their beliefs? With the best of intentions, when we design strategies and implementations, the cultural component, unfortunately, is discussed after the solution has been made or purchased. I think back, I know this is not, specific to every ACHE member, but it's one that sticks with me.

So, after having a child, you're a new mom, given a kit of tools to self care, feel like yourself again. And I'll never forget the fine toothed comb that was in my kit and how a woman of color with curly hair, with thick curly hair, what am I going to do with this fine toothed comb? And I think it was well intentioned, but the idea of accessibility culture can't be an afterthought as we think about serving everybody.

Host: I'm glad you talked about this. And so let's move on to just disparities in quality of care. Disparities in quality of care contribute to health inequities. So talk a bit about some of the inequities you've seen through the lens of your work.

Jessica Jamison: In colorectal cancer screening, disparities persist for a number of reasons. And while insurance and cost of screening is an incredible hurdle, 60 percent of those unscreened for colorectal cancer, are insured. And historically, marginalized groups such as American Indian, Alaskan Native, and Black and African American populations report not only higher incidence than other ethnic groups for the same disease, but their disease leads to mortality at higher rates. So, are there cultural reasons to this?

Absolutely. And how I come about it is, just organizing different interventions and initiatives, looking at levels of knowledge and awareness, maybe fears of screening or mistrust of healthcare. So just identifying these cultural elements within a specific program.

Travelle Ellis, MD, PhD: Disparities and accessibility are hand in hand. We have to think more upstream when we want to dismantle disparities, or give people more access. I say that because the systems that marginalize individuals or that impact their health outcomes, many of them, as everyone knows, happen outside the walls of the hospital or the system.

And so ensuring that accessibility happens, disparities gaps are closed, and it's culturally congruent is the idea that we have to invite the communities in. We have to go upstream, make sure that they're at the table, their voices and the end users considerations are actually implemented. It's awesome that a lot of our health systems have these, like, neighborhood models, but when a neighborhood clinic is stood up without community input, the community is not going to go there. It's a lot of money wasted, and healthcare doesn't improve or the healthcare disparities don't improve just because a building was built.

My colleague Jess talked about trust, trust is critical to ensure cultural accessibility and closing disparities. We have to make safe spaces for individuals that have felt marginalized, for individuals who have felt distrust for good reason. And so as we think about policy and being inclusive, I just encourage our systems to think about accessibility, not with the end product, but going way upstream.

Host: You mentioned safe spaces, so are those safe spaces being built? To what extent is this really a priority for health care?

Travelle Ellis, MD, PhD: I would agree. And safe to who, right? Is it safe for people who have infrastructure and access and someone to drive them and think about the time of day? Is it safe to give your information? Is it trustworthy that it won't come back on you? Somebody won't show up your doorstep afterwards?

Patients are very mistrustful of what they give because of the power that medicine and the systems have. They often don't feel like they have that champion. And so I know that community health and health equity are a big focus for ACHE and for our health systems. And inclusive of that is not just delivery of care, but also who works in the hospital and what's being said about certain patient populations and do they feel like they're seen and well cared for.

Host: Now, we know that data can be used to identify and address health disparities effectively. What do you see as some of the challenges in collecting and utilizing data to advance health equity, and then how can these challenges be overcome?

Travelle Ellis, MD, PhD: Data is a tricky thing. There's a plethora of data out there yet. Yet, there's not a lot of data as we start to segment by subpopulations or marginalized populations. And while data is an amazing tool to tell us exactly what we want to know, it can also tell us what we don't know, where the gaps are, and if we're brave enough, how to orient ourselves to then improve these outcomes. We often peel back the onion on our data and sometimes if you don't ask a question from the lens of the marginalized patient or the inequities, you can say, oh, the data looks fine, but looks fine for whom? And sometimes it's the 20 percent that the data is showing us rather than the 80 percent that we need to subdivide and really understand why.

Another point about data that we have to be mindful of is that as we leverage artificial intelligence and machine learning tools; data is super smart, but data can also perpetuate bias if we don't think about the algorithms that we're using to train the data machines. And so when algorithms were created, some of them took a lot of assumptions about race, ethnicity, and health outcomes. And therefore the underrepresented continue to be underrepresented and more harshly marginalized. As an example, they just pulled back race based algorithms in kidney function. And so to that end, data can be an awesome tool to inform our decision making, if we let it. We have to let it in, we have to inform it, but we also have to use it to ask the questions for those that need it most.

And so being balanced with our use of data and honoring those that are in marginalized communities with data, studying the questions that need to be answered to improve their outcomes and returning the data to them, I think is what the recipe needs to be to improve outcomes and more equitable situations.

Host: And do you see that as a priority?

Travelle Ellis, MD, PhD: Absolutely. We have so many interventions that we haven't necessarily correlated the data to say what's working. In my mind, if we think about the cost of care and how to prioritize our research, our data must inform us of where to go, who needs the most, rather than dispersing sparse resources widely and really concentrate our resources to the people that need it.

Jessica Jamison: I'm really excited about the inclusion of real data or race, ethnicity, and language, especially around the HEDIS measures. I think that it's just taking a huge step forward so that we can get accurate data on who is being screened for all measures across the board. I'm really excited on this change that's happening across the nation.

Host: You've touched a little bit on this, but how can research be conducted in a way that is inclusive and representative of diverse populations?

Travelle Ellis, MD, PhD: So I can talk about research. When we think about research, it's really conversation about a balance of power. We make research inclusive and representative when we include and engage the communities that are being researched. They need to be included in the trial design. They're essentially, the subjects, right? We have to change our language about it. So, instead of researching on diverse populations, we research with diverse populations. Perhaps that means that trials have to move outside of the hospital setting to different centers of care, or maybe some of the researchers that make decisions have mixed methodology backgrounds, right?

It's not just quantitative measures, it's sometimes it's qualitative, or maybe there's informed questions that come from community members or people without degrees. We have to think about collaborating with different stakeholders such that the studies can be more representative. And then when we get to the place of publication, invite the same diverse groups back to the conversation, thinking about how they informed the upstream, they should, celebrate the effects of the downstream, allow them to be a part of the implementation. Because I'll tell you, their insights that inform the data, they're going to be the first champions on the pull through. And so creating kind of an end to end with our research, I believe it takes research from just words on a page or data on a slide to real world impact. And therefore the power transfers again from an academician to a community that's uplifted because of the academic work that was done.

Host: Those are some great insights there, involved in the design, collaboration, and being part of the implementation. So, how can we scale successful health equity initiatives to have even a broader impact?

Jessica Jamison: So within my career, in working with federally qualified health centers, just leveraging and expanding your reach was a must. So looking at possibly like partnering with lab techs or a pharmacy team or even community health workers or community health reps to expand your education, expand the knowledge to create that behavior change for the patient was a must.

And I'm thinking, as a majority of states across the nation are really leveraging, especially through the pandemic, the expanded workforce of community health workers, I think that this is an element in a channel of the workforce that needs to continue to expand and thinking how we can go ahead and leverage outside the typical norms, especially around education and building the health for all.

Host: How can individuals, organizations, and governments collaborate more effectively to promote health equity?

Travelle Ellis, MD, PhD: I'd first like to orient us on this idea that health equity is as much of a journey towards health equity as it is a destination of achieving health equity. The idea of health equity may seem new to some that are coming to this game. However, inequities have persisted for generations and even centuries.

And so, if you think about what's happened to Jess's point earlier with the changes in HEDIS, the changes in government around reporting and accountability; some of these things are happening. And so the question is not just the step one of capturing the data, but the step two of how do we then make sure it's an impactful one? I would say there's probably three examples of this. So one, quality ratings. NCQA has a current tagline out right now that quality care is equitable care. And that's so true. The idea that even if someone's getting a cancer screening, is it a quality one. It's not enough to just check the boxes and say they were screened, but does it meet a benchmark?

 Can we lean on that screening to show that this patient won't have bad outcomes? Number two, I would say, once we get the data, now what? So the National Minority Equality Forum leans in here where they really lean into the social determinants and really the political determinants. The idea that a lot of the access is because of finances and policy decisions, both large P policy, governmental policy, but small P policy of how things are implemented in communities and in centers of care. So what can be done to look at those policies again? Are they working? Do they need to evolve?

What are the collaborations that need to happen to make sure that a patient's journey in overcoming their disparities, is not riddled with more barriers, in the desire to remove barriers? The last vision for the future, if we were going to vision cast, is that public health needs more infrastructure.

 COVID was the best and worst example all at the same time of highlighting, if a public health practitioner would have told you who would have been sick and who would have been the most impacted from COVID, they're the same populations that are disproportionately impacted for most every disease.

And so, to the point of we want to achieve health equity, we're on a journey towards health equity. Accountability is important. Collaboration is important. But we need to take a different approach. We need to take a population approach such that we're not maintaining the status quo or putting a band aid and the run out grants that then run out.

We're really thinking about sustainability and a future that really serves the needs of individuals the way that they want to be served.

Host: Travelle Ellis and Jess Jamison, thank you for your time and for sharing your expertise about the journey to health equity. Thank you so much. To learn more, visit ache.org/healthcareexecutive. If you found this podcast helpful, please share it on your social media. And for other topics of interest to you, check out our full podcast library. This is Healthcare Executive Podcast from American College of Healthcare Executives. Thanks for listening.