Searching for Equity in Healthcare

Jay Getten | Jun 27, 2021 | 12 min read

Is the US healthcare system equitable? This question has repeatedly run through my head over the past several weeks. Based on my experience as a healthcare provider, I can say anecdotally that equity has been the exception and not the rule. However, my own experience was not enough to quench my need to understand the underlying issues that influence inequities within the system that seems to plague both patients and healthcare professionals alike. In this article I aim to further explore relevant literature to identify specific disparities, underlying factors, and potential solutions.

Inequity Within Healthcare Organizations

Workforce Shortages

As a result of the covid19 pandemic the US is facing significant workforce shortages among entry level workers. To battle the shortages, large corporations, including Amazon, Chipotle, and McDonald's, are luring new workers with some of the highest starting hourly wages in history. While Walmart has offered new employees $15 an hour and other benefits such as degree programs (Parata, 2021).

Non-hospital healthcare organizations have long struggled to pay entry level staff competitive wages and the steps corporations have taken to increase wages have substantially widened the gap. Some specific examples include behavioral health peer support staff, long-term care workers, family support assistants, front desk staff, and medical assistants. These healthcare professionals support our communities most vulnerable populations (elderly, people with chronic physical/mental illnesses, and people struggling with addictions), with limited resources, and make significantly less than their corporate peers. If anything the last year has shown us is that entry level healthcare staff are frontline workers who face great health risks, anxiety, physical challenges, and work-related stress inherent in these positions (Fischer, 2021).

The Substance Abuse and Mental Health Services Administration (SAMHSA) predicts significant behavioral health provider shortages in vulnerable and underserved populations by 2025. SAMHSA estimates that 999,170 behavioral health professionals will be needed to meet rising mental health demands by 2025 compared to 762,290 available behavioral health professionals (Good Therapy, 2019).

The above numbers indicates that there will be a significant need for mental health counselors, family therapists, and social workers in the next few years. Of all the professionals that work in agency settings they often experience the most financial inequity. In 2014 the median salary for mental health counselors $32,599. Those who work in agency settings are grossly underpaid despite years of education and training. Nearly two-thirds of mental health counselors have master's degrees or higher (Christie, 2014).

Unfortunately, the above median salary has improved little over the years especially among counselors who work at community mental health centers (CMHC). Many CMHCs start masters prepared counselors at $17 dollars an hour, which is the starting wage at some Taco Bell locations. Historically, social work was never viewed as one of the highest paying positions and in 2020 the median pay for social workers was currently around $50,000 (The Realtime Report, 2020) which is significantly less than other masters prepared healthcare professionals (i.e. NPs and PAs).

Salary inequities are often shaped by policy makers who do not see the value in the services social workers and counselors provide. Behavioral health services are often one of the first things the government cuts in a budget crisis (Christie, 2014). How services are delivered also influences financial inequities within the healthcare system. The cost of health care in the US is near 18% of the nation's GDP and rising (Baucher, 2019) with hospitals accounting for 70% of the costs (Topol, 2019). Unnecessary hospital services account for much of the total GDP. For example, in 2012 critical access hospitals received around $2 billion dollars in Medicare payment adjustments to support underutilized inpatient services, when the money could have yielded greater value to preserve emergency services (Iglehart, 2018).

Such expenditures are surprising when 84% of all spending is consumed by patients with multiple chronic health conditions. According to the American Hospital Association addressing social determinants of health is critical in supporting high acuity patient populations and reducing healthcare costs (Iglehart, 2018). Yet, it is interesting to hear policy makers complaining about healthcare spending while at the same time cutting funding for the very professionals (counselors, social workers, peer support specialists, family support assistants, etc..) who support complex patients in addressing social determinants of health.

Falling on Deaf Ears

Sadly, healthcare professionals' clinical concerns or recommendations too frequently go unheard by healthcare leadership. Their concerns often cannot be heard over the noise of regulatory issues and productivity demands. Doing more with less has become synonymous with agency work due to shifting political priorities and reimbursement rate reductions. For example, most community health centers employ 20 (follow-up) and 40 (new patient/annual) minute visit blocks for primary care providers (PCPs) schedules. PCPs regularly must meet strict productivity standards which are unrealistic because community health centers provide services in rural and underserved areas with high levels of patient complexity. Primary care teams often face no-win situations where they must choose between meeting the needs of their patients or productivity quotas.

For many health systems employee satisfaction and organizational commitment are often overlooked elements that improve patient outcomes and enhance competitive advantage. What health systems fail to recognize is the lack of job satisfaction and organizational commitment felt by healthcare providers and support staff leads to decreases in quality of patient care and as a result a decrease in patient loyalty that ultimately leads to regressions in health system profitability (Tekingündüz et al., 2015).

How the Healthcare System Reinforces Patient Inequity


Many health systems as well as health information technology vendors often incorrectly assume a level of eHealth literacy of patients as a pre-requisite to participate in care delivery methods. The design of eHealth software (i.e., patient portals) and devices for engaging end-users in chronic disease self-management inadvertently re-enforces inequalities experienced by vulnerable/underserved populations. There are large numbers of patients who, because of a variety of situations are not able to engage with these processes or when they do, actual benefits are unidentifiable due to their circumstances (Botin et al., 2020).

Medicaid and Medicare Reimbursement and Recognition

Medicaid and Medicare are the largest insurers in the US. Despite allowing access to care for millions of Americans both unintentionally reinforce healthcare inequities. Many CMHCs around the country are in jeopardy because they do not receive federal grants or enhanced Medicaid reimbursement rates to offset the high levels of uncompensated care. This places CMHCs in a vulnerable position and contributes to workforce shortages due to their inability to pay mental health providers competitive wages and keep offices open (Loveland, 2016). Mental health providers leaving for private practice is a direct result of limited Medicaid reimbursement rates influencing salaries. However, reimbursement rate issues follow providers into private practice causing many mental health providers to turn away the people they initially got into the field to help because they no longer accept Medicaid's low reimbursement rates.

Medicare has not updated its qualification requirements for behavioral health providers since 1989 when clinical psychologists and clinical social workers were included (Wiley et al., 2019). Several key frontline mental health providers are excluded from Medicare policy. Most notably licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs). Needlessly excluding LPCs and LMFTs from Medicare reimbursement strengthens disparities and increases obstacles for older patients seeking mental health care.

The collaborative care model which integrates behavioral health with primary care has proven to be a highly effective method in reducing comorbid depressive symptoms among patients with chronic health conditions and in 2015, Medicare started offering care coordination reimbursement codes to increase collaborative/integrated models of care. Yet, only saw a five percent uptake on these billing codes due to low reimbursement rates and system barriers. Instead of embracing all-inclusive approaches to care too many health systems must provide direct patient encounters to remain viable. As a result countless collaborative care programs have been short lived because insurers inability to adequately reimburse care coordination services (Williams et al., 2019).

For more information: A Cast for Collaborative Care

Potential Solutions

Corporations to the Rescue?

Private equity investors are poised to capitalize on new opportunities in the healthcare marketplace. Specifically, investing in companies that serve vulnerable and underserved populations covered by Medicaid and Medicare. Venture capital investment firms are buying primary care, urgent-care, and mental health practices. They are investing in patient engagement technologies and organizing care in a way to maximize revenue, operational efficiency, and customer satisfaction (Levkovich & Nielsen, 2019).

Private equity firms can understand and analyze cost data, something that most nonprofit health systems do not have the capacity to do. Strong data analytic capacity allows venture capital firms to negotiate better reimbursement rates from insurance companies which creates equity for healthcare professionals through better salaries and benefit packages. These firms can also meet the growing demand for customer convenience by providing care when and where the customer wants it at a reasonable cost (Levkovich & Nielsen, 2019).

Healthcare Cooperatives: Democratization of the Workforce

Healthcare worker cooperatives are businesses owned by the workers. Workers are accepted as cooperative members based on predefined criterion. Each member of the cooperative becomes an owner with rights and obligations that include participating in workplace decisions, contributing labor or skills, receiving an equitable share of profits (Hansen et al., 1997). Healthcare cooperatives aim to bring together healthcare professionals and patients to reconcile misalignments between supply and demand. They seek to engage all stakeholders involved in healthcare, jointly manage costs and risks, and achieve the utmost quality of care (World Health Organization [WHO], 2019).

Healthcare cooperatives are able to quickly adapt to new socio-economic contexts, while being an ideal framework to resolve new needs. Healthcare cooperatives can adjust to vastly different health needs within communities. This is largely due to governance models concentrating on the pursuit of solutions to the needs of people and their communities. Solution focused approaches allow cooperative models to evolve and reinvent themselves in response to new problems. Healthcare worker cooperatives seek to generate employment on equitable terms for healthcare professionals to freely practice their profession in a way that is not subject economic factors that impose on their professional judgment (WHO, 2019).

Healthcare cooperatives demonstrate that improvements in health care service can be reached through pooled resources and healthcare professionals enjoying better working conditions. Cooperatives are good at blending professionals' skills and financial resources to respond to market failures in serving the interests of staff and patients while providing services that would be otherwise inaccessible. Cooperatives highlight addressing the needs of their stakeholders and communities at large by improving accessibility to health services for populations who would otherwise be excluded (WHO, 2019). The healthcare cooperative model's democratization of the workforce and its ability to adjust to changing economic, social, and political conditions more readily than conventional healthcare organizations makes it a viable option to increase equity for patients and healthcare professionals.


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