health disparities and health equity

As a graduate of Duke University’s Fuqua School of Business, ApolloMD President, Yogin Patel, MD, MBA, FACEP, recently participated in the Fuqua Forums alumni panel series for a discussion on the impacts of social determinants of health care (SDOH). An insightful and timely conversation, the subject brings into focus the correlation between access and outcomes for patients of various population groups. Dr. Patel’s approach to advancing health equity comes from his direct EM experience as well as his system-wide data and observations.

For the purposes of this exchange, the moderator defined the pertinent social determinants as:

  • Access and quality
  • Neighborhood and environment
  • Social/community context
  • Economic stability, and
  • Education.



Health Disparities and Health Equity

“Our group serves about 3.5M encounters across the country. Some of our partner facilities are large tertiary care centers and some of them are small rural hospitals — sites that are the sole access point for health care in their community, often serving the underprivileged or those without resources for specialty care.

In one respect, [the ER is] the great equalizer in many communities; it’s open 24/7, you don’t need appointments, and you don’t need insurance. The reality is that when you’re going to the ER … you’re a patient with a crisis and the question is how much of the social determinants in your environment are contributing to your illness.

A full 50% of someone’s health outcomes may be determined by factors such as racial discrimination, income inequality, food insecurity, or addiction.

This is a challenge, and I think an opportunity to think about technologies and innovations that help risk-stratify patients earlier, to pull together resources, to create an effective health equity policy, to make those available in real time to patients in need, and also to study the impacts of critical social determinants of health with specific disease processes. I believe there has been a broad realization, especially mid-pandemic, that social risks absolutely compete with health outcomes.


addressing social determinants of health in primary careSo, what tools are available and how do we pull those together? This varies by community—well-heeled communities are going to tend to have better resources locally. Every large health system, nonprofit and for-profit alike, will tout food-pantry programs and in-hospital pharmacy and fresh food buses that may be available to select populations, but … [in smaller, more rural areas] how do we make sure a discharged patient takes full advantage of the resources available?

Communities without a wealthier tax base will have fewer programs; how do we flow resources there at the provider level where they can actually link them to the patients?

Scalable Health Technology

health equity metricsThis is where health tech becomes so interesting, whether it is an AI-based screening algorithm or teleconsultation and telehealth care coaching. Those are interventions that are scalable and may reach those who traditionally have been disenfranchised… [i.e.] if transportation issues exist, using telemedicine to reach patients at home (if they have internet access and a smartphone) is a much more scalable solution than expecting them to navigate bus schedules or call a ride service. Again, I think there is an opportunity here not only in matching patients to technologies, but also in cultivating and developing those technological resources.


Social Channels and Peer-Coaching

One thing that is lost in all of this is that health literacy in general is low, and the impact of peers and peer-coaching is actually always underestimated. If at the point of discharge there’s a way to link an at-risk patient with similar at-risk patients in their area, that can educate a community and foster peer-accountability. This idea seems a bit like microfinance and micro-lending, and it has great promise through using these social channels and peer-coaching to achieve better outcomes.

We need to start thinking about how to infiltrate geography in underprivileged communities in a way that is affordable and accessible. Maybe the nexus for some of these programs is not the hospital or emergency department; maybe accessibility comes from non-traditional means—like a dollar store or a chain barber shop or grocery.

race and ethnicity as a social determinant of health

When it comes to the provider side of identifying and managing patients who need support in the realm of SDOH, there is a paucity of this training in medical school curriculum, even in residency. I’m 20 years out of medical school and at the time it was very limited and has not moved dramatically. This is such a large, complex, multifactorial problem. If you’re a resident in training — studying acid-base disturbances and vent settings — homelessness in a community is one of these esoteric problems that doesn’t have a solution, other than involving case management when presented with an SDOH.


The challenge that we can bring from the business community is making those solutions digestible and actionable at the point of care. It doesn’t always have to be expensive. I’ve referred to this idea of a health coach several times with the notion of securing an interloper to improve health literacy and patient outcomes. Whether that role emerges from traditional health care delivery, such as doctor’s offices, hospitals, and health centers, or from a community-based resource, it’s increasingly important [to investigate] if we want to impact communities at-risk.”