By Michelle Morse, M.D., M.P.H., chief medical officer, New York City Department of Health and Mental Hygiene; and Adriana Joseph, M.P.H., health system specialist, Office of the Chief Medical Officer, New York City Department of Health and Mental Hygiene
The COVID-19 pandemic exposed the fissures in our society, but as history has shown, crises can lead to unprecedented collaboration. In New York City, collaboration among public health and health care organizations resulted in the vaccination of 6.5 million people in less than a year.
Building more bridges between public health and health care can help us prepare for future emergencies and collectively tackle longstanding health inequities. The health care industry’s focus on treating diseases while deemphasizing efforts to prevent illness and invest in communities has taken a toll on Black people, Indigenous people, and people of color (BIPOC), who shoulder greater burdens of disease and poor health because of systematic disinvestment and historic exclusion from health care.
Instituting Two-Way Communications
Recognizing these challenges, New York City’s Department of Health and Mental Hygiene last year created a new chief medical officer role, tasked with strengthening relationships between our agency and health care organizations. With Commonwealth Fund support, the newly inaugurated Office of the Chief Medical Officer created a strategic plan that outlined how our public health system can partner with the city’s health care organizations to advance health equity across the city and promote antiracism in health care.
To start, we wanted to understand what had and had not worked well in past partnerships. We spoke to leaders of 15 hospitals, including academic medical centers and safety-net institutions. We learned that the relationship between the health department and hospitals sometimes felt one-sided to them, with the health department only coming to hospitals when it wanted them to do something.
Many hospital leaders told us they were committed to efforts to advance health equity but didn’t know where to start. They wanted assistance in making sense of data about patients’ race, ethnicity, and preferred language, as well as guidance on leveraging resources to address the social determinants of health. We have responded by working with the state to support and shape health equity priorities and investments under a Medicaid waiver currently under development.
We are now focusing on increasing our engagement with providers, including an updated version of the emergency health alert system that will allow us to better understand the effectiveness of our emails. Previously we were unable to track email open rates and the reach of our provider communications; now we can use these data to better tailor our messaging. We’ve also convened a group of BIPOC clinicians who update us regularly on emerging priorities and issues in the communities they serve and offer suggestions on how we can implement an equitable response.
Prioritizing Health Inequities
Health departments can provide health care organizations with timely information about health inequities and ways to reduce them. In New York City, the health department has been tracking the disparate impact of the pandemic on BIPOC residents. A recent report found that during the Omicron surge, the COVID hospitalization rate was more than two times greater among Black than white New Yorkers.
The department launched a “Use Every Opportunity” campaign to reduce inequities. It offers tools to help providers use every encounter as an opportunity to vaccinate. For example, our office held a workshop last week for clinical leaders to learn from a hospital system that had successfully implemented inpatient COVID-19 vaccination as a health equity intervention through order sets and best practice alerts in the electronic medical record. The department also has been educating providers about antiviral medications and urging health systems to track how many COVID patients receive treatment.
Last November, leaders from 12 New York health care institutions joined a coalition convened by the health department in the Coalition to End Racism in Clinical Algorithms. Members committed to ending their institutions’ use of race adjustments in clinical algorithms for kidney care, maternity care, and lung function, and in other areas. Not only do such formulas propagate the false view of race as a biological, rather than social, construct, they can perpetuate racial disparities in access to care.
For example, the two most commonly used formulas used to calculate kidney function report higher values (i.e., better functioning) for Black than white patients who have the same blood test measurements (creatinine). This means that Black patients whose kidneys are deteriorating may get referred later than white patients for specialist care or transplant evaluation. The coalition is creating opportunities for health systems to learn and act together, and members have pledged to end the use of at least one race-adjusted clinical algorithm, measure the impact on related racial inequities in care, and develop a patient engagement plan.
Health departments can hold health care organizations accountable and vice versa. In 2013, New York City became the first local jurisdiction to launch a Severe Maternal Morbidity Surveillance System to track complications of pregnancy and childbirth, such as infections and hemorrhage. The system found such events increased 28 percent from 2008 to 2012; near-death experiences were more than three times as common among Black people as non-Hispanic white people. In 2018, these data led to the creation of the Maternity Hospital Quality Improvement Network. The health department uses it to work with hospitals to review cases of severe maternal mortality and promote best practices, including training providers how to listen to and show respect for people of color.
The health department is planning a citywide health equity dashboard to publish data on metrics such as racial and gender diversity of executive leadership and outcomes related to birth equity, chronic conditions, and behavioral health, among others.
Sustaining Partnerships to Advance Equity
By creating roles like chief medical officer and chief equity officer that are focused on antiracism and equity, health departments can begin to create infrastructure where these principles are integral to decision-making and strategic planning. Though these positions are just a start, they create a path to put plans into action so that public health leaders can build sustainable partnerships with health care delivery organizations to reduce inequities, undo racist policies, and work together to advance health equity.