Health Equity Conversations
Through Health Equity Conversations, Joshua Liao hosts a series of discussions featuring people and groups around the country working to improve equity and health through systems change.
In this episode, Josh spoke with Utibe Essien, MD, MPH, Assistant Professor in the David Geffen School of Medicine at UCLA.
This interview is a condensed version of the conversation between Dr. Liao and Dr. Essien, and has been edited for clarity and length. For full-length discussion, please access the audio recording (available episodes accessible via Apple Podcasts and Spotify).
Joshua Liao: Thank you so much for joining us today. I'm really excited to have this conversation with you.
Utibe Essien: Likewise, thanks so much for having me Josh, I appreciate it.
JL: Could you begin by sharing a bit about your background and the journey you had to your current research career?
UE: Absolutely. I am an Assistant Professor of Medicine at the David Geffen School of Medicine here at UCLA. It
Utibe Essien, MD, MPH
has definitely been a journey to get out West. I am a New Yorker, born, raised, schooled, as I like to say, and child of Nigerian immigrants. My parents met there before they came out to the States.
My dad's a primary care doc and so I think in some way put the medicine bug in me and my three siblings. I’m the only one who chose this esteemed career, but growing up I didn't really think medicine was going to be for me. [My dad] was working way too hard, had to repeat residency here in the States, so that struggle was pretty real. But after getting a chance to work with him as a primary care doc, and seeing the impact he had in his community, I was like this seems awesome, this feels like a really great way to make a difference in the world, as cliché as it sounds.
So, I ended up going down that pathway. I was a pre-med at NYU in New York City and volunteered in the emergency department at Bellevue Hospital in the city and kind of had my first experiences around unjust or inequitable care, really seeing immigrant patient populations and homeless individuals really using that emergency department, which is where I volunteered, as their primary source of primary care.
I think that was the first time that I was seeing this kind of a juxtaposition of health care being provided. But you know, I was going on, was way too focused on being a pre-med student, getting the MCATs done. And I had the opportunity to train at Albert Einstein in the Bronx. Fast forward to going through the pre-clinical years into the clinical years, and again saw that juxtaposition when we’d rotate through our different hospitals in the third year where some rotations would be at the public hospital where we would not really see a lot of resources for our patients. I would be doing all the blood cultures and running labs downstairs, versus when we rotated at the private hospitals where you’d see family members lining up at the bedside, and the patients asking, “why is there a student in the room with me?” Just very different care settings. I think those experiences really got me into this health equity space.
Then fast forward through to residency, I had a chance to train in Boston as a primary care resident, following my dad's footsteps, out in Chelsea, Massachusetts which is a city out in Eastern Boston, largely Spanish-speaking immigrant population. And again, kind of seeing this gap, this juxtaposition, between who had access to care when we were rotating in the hospital across the bridge in Boston versus when I would go out to my community health center.
The thing that really stuck out to me I think was when I got to residency, I thought you know all my training, all my experience, I'm going to be this social justice warrior guy who finally gets to help my patients get the care they need. But there's just so much more than me just being able to prescribe a right prescription, or recommend the right screening for my patients. They just had so much more in their lives to be able to get the best care, and a lot of that was just based on who they were – whether again it was because of their primary language they spoke at home, because of their ability to make wealth, because of their jobs, because of their immigration status, and that's just continued to drive the work that I do – the specific research I do around cardiovascular disease, the work I do around social determinants, the work I do as we’ll talk about around pharmacoequity. I think that's kind of the journey that it's been so far. Hopefully there's still a lot more to that story in 5-10 years and we can get on another podcast one day.
JL: For sure, I'm going to hold you to that. As you alluded to, an important concept in your work is pharmacoequity. For those who may not be as familiar, could you explain it and some implications of achieving or not achieving pharmocoequity?
UE: As I mentioned, this has kind of become one of the primary focuses of my work – really thinking about patients getting access to the care that they need. We define this term as ensuring that all patients regardless of race, ethnicity, social class, access to resources, has equitable and affordable access to the highest quality medications they need to manage their health conditions. And again, as you mentioned and alluded to in your primary care experience, mine as well, we just see time and time again that so many patients do not have that access, and that so much of it is based on access to resources, is based on bias in care, as sadly study after study has shown.
We argued in a piece that we published a year ago now in JAMA that we really can achieve that goal and that achieving it will help us reduce health disparities. I think a lot of the work around health equity is focused on addressing social determinants like housing and food; is improving access to insurance; is getting patients to not live in health care deserts or pharmacy deserts as we might talk about a little bit more. But even when patients make it through all those steps, they fight the challenges around food insecurity, around homelessness, around bias in care; that there are still those who come into the clinics, who come to the hospitals, and who walk out without the same level of care as folks who look a different way or who have access to different resources.
So really that's the goal, is that that should not exist when folks make it to us in the health system. And sadly, study after study has shown that it does. I think the implications for not achieving pharmacoequity, I'll start there, is that we’ll continue to have an unequal health system. We’ll continue to have a health system that unfortunately produces a two- to three-year gap in life expectancy between White and Black Americans, White and Hispanic Americans, and even wider when we compare between White and American Indian/Alaska Native individuals.
We’ll continue to have disproportionate rates of cardiovascular disease, of cancers, of course over the last few years we can't have a conversation without talking about COVID, right? So those are the implications for not achieving this goal. And I do think that if we do achieve [this goal], and a broad approach to doing so, we can actually really start to make some dents in achieving health equity.
JL: Let's go back out to the community because I think often this is a concept that's invoked when we talk about social drivers of health and social determinants. What types of community investments might best promote pharmacoequity in your mind?
UE: I think it's a hugely important question because some may say, just get everyone insured and we'll be able to address pharmacoequity. I think that's part of the solution, absolutely. We still have 20, 30 million Americans who are uninsured; we still have states that have not expanded Medicaid to help those who are of low-income backgrounds. But the actual [health insurance] card does not quite get the patient the medication that they need in every case, doesn't get the patient or community member the knowledge around these new therapies that are available, or the guidelines or the recommendations for whatever their conditions are.
I think that's where those community-based, the place-based programs you alluded to come in. I think that's where we can really invest. I've been spending a lot of time trying to pivot a little bit from saying that health systems need to be the only primary investor in that. I think health systems have a lot of roles, including ensuring that we are non-biased providers of care. But I do think we have to look beyond the hospitals and beyond the clinics to be able to also go out to the barbershops, salons, churches, schools to make sure that patients are getting equitable care. We have to trust that our policy makers, the corporations that are benefiting from the work of the community, both the physical work and the financial work, are also being involved in these key investments.
So I think, yes, on the health system side we can get creative about that. But in my mind, we have to really start to push our policy makers. I think a lot of the work that you're doing as well Josh, to see this as a priority and really start to invest deeply in it.
JL: What are we measuring currently in the US with respect to the quality of therapeutic care that you think could help intervene, track, or even report on improvements in equity?
UE: Yeah, it’s a great question. I think what we are measuring right now is who gets what. For example, I study atrial fibrillation, we have a patient who has an A-fib diagnosis, we know what their risks are of developing a stroke and who needs to be on a blood thinner. We have that information, we can look through “insert your electronic health record system” and see that information. We've gotten really good at that over the last couple of decades – the calls for improving quality of care. We've got in the VA [Veteran’s Affairs] where I practice, a chief resident in quality and safety. We have these vice chairs, deans etc, of quality and safety. So we've gotten really good at that, but how do we pivot it to the equity space?
And I think the reason we haven't been as smooth in that pivot is until a couple of years ago, in some spaces, that has not necessarily been a priority. Obviously, the pandemic and the conversations around racism as a public health issue have really highlighted health inequities in ways that – I imagine just from talking to my dad and other mentors – we just haven't seen before. So I think that's a big reason why we're having this conversation more. And then the fact that it has been so challenging to actually collect data on race and ethnicity. So that's not the be-all, end-all for pharmacoequity, but that’s a key place where we see differences in care, right? So whether it's the concerns around the collection of those data, what are you doing with this information?
We have a health system sadly that has a legacy of experimentation, especially around research. And so that legacy is still there embedded within our systems, so people worry about reporting their race/ethnicity data, don't want to do it. Who is considered White versus Asian versus Black has changed so much over the last centuries, so to really know what to do with that information. But I think now is the time for us to really get as creative, as nuanced, as diligent as possible in reporting data around race and ethnicity especially when it comes to these quality metrics – that every health system should be able to know how they’re doing in treating hypertension, and treating diagnoses like A-fib and treating pneumonia, and who is leaving the hospital with the appropriate medical care. I think that that will be a measure that will really help us to be able to track pharmacoequity down the line.
JL: How do you think about the gaps in the data? Do you think it's getting better individual data? Area-level data? What's next to practically make the next step?
UE: I think what's next, first, is not allowing the limited data to hold us back. So, I've heard arguments over the last two years that have said, well you know the data aren't clean enough, they're not ready for prime time, so to speak, so let's just skip these questions, let's focus on something else, something where the data are better. I think that's dangerous, right? We know that there are problems, they're hidden in some of the missing data that we have especially around like we mentioned race and ethnicity, so for us to just completely let that go I think gets really dangerous. And then we end up missing out, and potentially widening the disparities down the road. So not saying to let it go.
I do think we should be doing both, so the efforts around, again going back to policy, the government around U.S. census data collection. Those are huge teams that got dampened by COVID sadly, but if we reflect back on 2010, there were teams that went out there, got into the neighborhood, went out to reservations, drove out to rural communities, really committed to getting that data right. I think that that's what we have to do as well. In the same way we want our brilliant scientist in her lab dissecting every mouse possible and finding every cell to target that one cancer that can change the world forever – that's the same way that we have to get creative with these health services methods. They haven't been, as you know, exotic or Nobel Prize-y over the last several decades, but these are the ones that are going to change and transform communities and, like you said, neighborhoods and the lives of individuals themselves. I think we can continue to push to get that data to be as precise as possible. We’re not there yet like you said. I think the area-level analysis such as neighborhood deprivation are huge and really helpful right now. I think they can inform us about a lot especially because we know when we talk about race and ethnicity, for example, that so much of the area-level outcome such as segregation, such as wealth, such as education have been based on racial differences and access and wealth, etc. So, they do give us a really helpful proxy and I think those are helpful places to start while we're waiting for the individual-level data to get more precise.
JL: You mentioned prescription drug costs, and they are certainly incredibly important. And yet, as you know, they don't exist in a vacuum; they exist alongside other costs. So take a step back: how do you think payment methods and in particular value-based payments, that at least aspire to engage clinicians in a way that drive good outcomes, how do these payments figure into pharmacoequity?
UE: I think that sounds like our future paper, Josh. I think for me the opportunity to take the funds, the resources that we're using on drugs to really invest in the social drivers of health is how I've been thinking about it. Again, giving talks around pharmacoequity, folks say, well is it really all about drugs? There are communities who don't want to take medications and are like keep your drugs to yourself, I'm going to do my thing with my family. There are others who are really so directly focused on, if we don't get folks housing it doesn't matter that they can't take their DOAC [direct oral anticoagulant], it doesn't matter that they aren't able to get to claim to get their chemotherapy infusion.
But I think that the amount of money that we're spending on drugs, on pharmaceuticals, and the lists go on in terms of the data around that – can we so shift it to focusing on the social drivers to help us as a health system get way more creative than we can be now, just because of again, what many others are more expert in – the balance books. There's not enough opportunity, not enough funding there to be able to build the shelter that a hospital may want to build when we're struggling with getting patients discharged from the hospital who are housing insecure, while we're spending so much of the effort and money on these medications.
So that's I think one of the ways that we can get more creative with the payment structure, is being able to shift funding from the medications themselves. Obviously, there's been some recent policy including what the Inflation Reduction Act for a very small group of patients, that will hopefully help us at least start to think about how do we negotiate for drugs as a federal government – drug pricing, what happens when there's caps on certain drugs, as well as caps on out-of-pocket spending, and how patients start to behave when those cost limits are there – I think are really going to teach us a lot about the future of payment, payment structures, and pharmacoequity.
JL: We've covered a lot of ground talking about foundational things like physically having access, insurance coverage. We've talked about things that happen between patients and their clinicians, about place-based programs in the community. Based on your work, what are one or two things you think, if changed, would yield the biggest improvements in equity as well as outcomes for historically marginalized communities?
UE: You know I’ve been thinking about that continuum for a bit and where do we actually plant the flag in it. Whether it's all the way at the beginning again, thinking about drug patents and why certain companies can continue to extend those time after time, even when there are plenty of drugs available, plenty of generic options available outside of our country, whether it's the clinical trial diversity and how using that information and sending it to the communities can help the communities be more informed, more empowered to get the right treatment, or going back to the providers and really letting clinicians and our colleagues know these are the data and this is how we can improve.
For me I think it's always going to be about making the right choice the easy choice. I’m thinking a little bit early, further down the continuum for us as providers – those who are listening on the call who are practicing tomorrow, so I'll give that downstream answer – and then the bigger upstream answer. I think until our electronic medical records, or whatever systems that we're using in our systems, don't really allow us to give a non-guideline based, non-high-quality medication to the patient in front of us, regardless of their insurance status, regardless of what they look like, what language they speak at home, that we're going to continue to see and have these subjective decisions. These you know, “I think they were pretty unsteady last time, we gave them medication, and I worry that they weren't really being compliant on this therapy.”
When the right choice is the easy choice, I think we help eliminate disparities and whether that's through nudges, through EHR-based tools, best practice alerts, that I think really is going to help us as clinicians get rid of some of our subjective biases that end up, I think, extending and winding disparities. Again, that said, we also know on the flipside a lot of the really meaningful conversations that we're having with our patients, around their inability to afford medication that may not make it into the EHR, nor might it make it to these large database studies that we lead. But we know that those conversations end up being why we don't prescribe medications to certain patients, and when there are groups in our country who have significantly lower proportions of wealth compared to others in the country, the opportunity to pay $100 or $500 dollars a month for a prescription, it’s just not available to them. I think that those are again way, further upstream where we actually start to deal with some of these wealth inequities in our society. I do think that the health system has a cool role that they can play in that and serving as an anchor institution and actually infusing funding and resources into our communities. Whether care payment structures and plans help to address that, I think that's to be seen in the future. I think there's probably a lot of cool opportunities to get creative there, but I think in reducing wealth [inequities] in the nation especially for the most marginalized communities and us as clinicians being able to make the right choice the easy choice, it will really help start getting us closer to pharmacoequity.
JL:Utibe, thank you again for joining us.
UE: Absolutely. It was a pleasure, thank you for helping to amplify this topic. I'm excited to keep brain storming ideas, both individually, together, but also with folks who are thinking about payment and equity and clinical care. It's an exciting time.