by Robin Stawasz and Duane Feger

Health equity means that every person has access to health care that meets their individual needs. While social, racial, and ethnic disparities affect health equity, a person’s ability to access primary care — the foundation for good health — has a strong influence on their overall health. Poverty, more than any other factor, affects that access.

Primary care is hard for low-income individuals to access for multiple reasons:

  • Too few facilities, especially in rural areas
  • Clinics and pharmacies located too far from patients’ homes or public transportation
  • Facilities are closed after work hours
  • Too few clinicians accept Medicaid coverage
  • Large Medicaid coverage gap in 11 states that did not expand Medicaid

Disparities in access to primary care are not only unfair to patients. They also cost our healthcare system billions of dollars that could be spent keeping people healthy. Patients without a primary care doctor use the ED when inexpensive, over-the-counter remedies don’t treat their illnesses or injuries. They’re not abusing the system. With no primary care providers to serve them, no insurance, or no health organization overseeing their needs, they have nowhere else to go.

Instead of working to change patient behavior, we need to develop a new system that locates and eliminates barriers to care. When we can make patient-centered preventive care available to everyone when and where they need it, we not only encourage good health, but we also reduce unnecessary high-cost care utilization across a community.

Addressing gaps in care

You can’t fix a problem if you don’t know it exists. Therefore, the first step toward health equity is to identify where gaps in care exist, where additional primary care is needed most, and what social and economic conditions are affecting access to care. Technology — after accounting for the inherent biases in data —  plays a big part in both locating gaps and providing insights on how to fill them. 

After three decades of electronic health record (EHR) development, however, few health systems offer a comprehensive view of patients’ medical journeys. Of the hundreds of EHR systems that exist, few are interoperable. Currently, most providers can only document what they diagnose and prescribe themselves or what their patients remember. They lack the tools to proactively manage care and transitions for their entire patient populations.

The healthcare industry is now working to achieve interoperability within and between healthcare facilities so that health data can flow freely, and providers can share and interpret information easily. Progress has been slow.

Addressing the interoperability challenge, CMS has recently piloted a program, Data at the Point of Care (DPC), to provide a select group of users with access to over three years of Part A, B, and D claims data on Medicare patients. This data can be integrated with participating providers’ EHR data. The next step is to utilize technology and deep learning to make data meaningful and close gaps in care.

For instance, using a technology solution combined with DPC, providers can view, at-a-glance, their patients’ complete health histories as well as treatment and medication compliance, regardless of where their patients have been seen or treated. Practice managers can review reports based on key indicators — such as quality of life risks, hospitalization and rehospitalization risk, frailty flags, medication compliance, psychosocial needs, and current oncological treatment — so they can evaluate the current needs of their patient populations and predict the resources they’ll need to manage care over the next months or years. Provider groups, ACOs, and health systems can review utilization patterns and determine whether their patient populations are getting sufficient, appropriate, and equitable care.

Developing new insights to improve health equity

While some healthcare organizations are singularly focused on how to reduce racial, gender, and social bias to improve health equity, others are using technology to gain insights into the strength of their care management programs and how well they are serving their less advantaged patients.

Consider, for example, a large health system in Florida that was able to identify the same group of patients who were returning to the ED almost weekly, being treated and discharged. The actual diagnosis, when investigated further, was food insecurity. These patients were using the ED for a free meal. The health system worked with a local pizza chain to send pizzas to their homes every week. The cost of several pizzas a week saved the hospital close to $250,000 in ED use over the following year.

In another case, a large primary practice with a full risk value-based contract recognized that a child with asthma had been hospitalized four times in the previous year. Each hospitalization cost between $20,000 and $30,000 and was affecting the practice’s ability to meet their cost control metrics. They sent a case manager to the home to do a health evaluation and discovered the whole house was carpeted. Some of that carpet had developed mold. The practice paid $5,000 to replace the carpet with solid flooring and the child’s asthma attacks stopped. The child had no hospitalizations over the following year, saving close to $120,000 in hospital costs.

In Southern California, a health system was able to identify and center their focus on 93 of their highest need patients and address the medical and social determinants that affected their health. They provided transportation to doctor’s appointments, home doctor visits, and cell phones for scheduling and telehealth visits. Over a year, they saved $6 million dollars — money that could be spent to maximize their resources and serve additional patients in need.   

Solving the health equity challenge can’t happen without a clear understanding of where inequities exist. When organizations have comprehensive data and insights that help them identify gaps in care, they can better determine financially viable mechanisms to fill them.

Technology, used appropriately and effectively, is a key strategy for addressing the needs of all patients, regardless of where or how they live.

Focusing on patients with the greatest need

Acclivity Health is a technology company that was formed to address the needs of the seriously ill population and ensure all patients are identified and treated with the care they deserve. The Acclivity platform helps independent physician groups, ACOs, MAOs, private insurers, and palliative care and hospice organizations assess immediate and future care needs — rather than past utilization.

Because Acclivity is one of the select vendors partnering with CMS in their Data at the Point of Care pilot program, we are uniquely qualified to identify gaps in care across communities as well as across the continuum of care. We empower our clients with actionable insights that lead to more equitable care and more efficient use of existing resources.

If you’d like to learn more about Acclivity and how we can help you improve health equity in your community, please contact us at or call 904 562 1368.