When Equality and Health Equity Diverge

September 28, 2022 Monica Soni, MD

Treating patients the same isn't always the path to improved outcomes.

The concept of equality has been so ingrained in Americans that we often accept it without second thought. What if I told you that, when it comes to health care, focusing on equality can take us down an unintended path? 

Don't get me wrong—we must be surgically focused on achieving excellent outcomes for all patients. We just won't get there by uniformly doling out identical care plans. We know definitively that a rising tide does not lift all boats in health care.

Consider, for example, screening for colorectal cancer. In May 2021, the U.S. Preventive Services Task Force lowered the recommended age for screening for this disease from 50 to 45 for all individuals. Yet, compelling evidence shows that Black patients are more likely to be under-screened, to develop colorectal cancer and to die from it.

While recommending younger screening for all sounds fair and just, how can our capacity-constrained health care system accommodate the added volume? What de facto rationing will occur on the ground level? Will groups who historically have had poor access continue to be left out?

This does not mean that we should reflexively let race, a socially constructed classification, or other characteristics dictate who gets which services or treatments. Rather, patient-specific contexts and preferences should factor into the process of shared decision-making.

A current study into breast cancer screening shows us what a successful approach might look like. Called WISDOM, this ongoing trial is comparing two groups of women: one that receives annual mammograms recommended by some guidelines, and another group that follows a personalized approach, in which screening frequency is based on several factors, including family history, genetic markers and personal preferences. I'm excited to see the study results and what they portend for tackling health disparities.

For example, given that Black women are 40% more likely to die of breast cancer, could personalized screening schedules help narrow that gap? Amplifying the patient voice and empowering patient choice could help mitigate provider bias.

Some patient differences already factor into cancer treatments, of course, but we need to look beyond biomarkers. Even more powerful and far-reaching is the impact of where we live. Stunning results from a study of patients with acute myeloid leukemia in Chicago found that Black patients had a 59% higher risk of dying from the disease. Yet, neighborhood characteristics, such as level of affluence and segregation, accounted for almost all of the gap. Until we address these core drivers of health, we continue to support unequal outcomes.

Combatting inequities will require a personalized whole-person approach that is informed by this kind of data. New Century Health and the health plans we serve have a leading role to play. For example, NCH tracks real-world data to assess how patient outcomes vary with ancestry-related genetics, functional status, the presence of food insecurity and other social drivers of health. We can then integrate those findings into our oncology clinical pathways, to identify regimens that are the best options for patients, considering all the factors at play.


About the Author

Monica Soni, MD

As Associate Chief Medical Officer, Dr. Monica Soni works to ensure high-quality, cost-effective care for patients and the best possible experience for providers. She is a board-certified, practicing internal medicine physician with over a decade of experience in both inpatient and outpatient safety net care. Immediately prior to joining New Century Health, Dr. Soni served as the director of specialty care for the Los Angeles County Department of Health Services, the second-largest municipal health system in the United States. She is also an assistant clinical professor within the UCLA Department of Medicine.

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