Mind the Gap: Listening to the Community Is an Underappreciated Strategy to Improve Health Outcomes

Contributor: Lisa K. Fitzpatrick, MD, MPH, MPA
To learn more about Lisa, click here.


In 2018, while serving as the chief medical officer for Washington, D.C. Medicaid, I was sitting at my desk poring over data in a consultant’s report. The health department had contracted with a public health firm to assess primary care access gaps in the District. I had been living and working across the D.C. health sector in policy, research, community engagement, and medicine at safety net hospitals for ten years. I knew these primary care access gaps well. Except for after hours — nights and weekends — Washington, D.C. did not have a shortage of primary care. The report concluded the same and instead highlighted a different problem: engagement.

Medicaid beneficiaries often preferred emergency care or no care over building a steady relationship with a primary care provider. I knew this from listening. Listening to my patients, to community members, to Medicaid beneficiaries. I decided to listen a bit more and interviewed a few people with recent visits to the emergency department. From these conversations, a few patterns emerged that highlight why, despite billions invested in healthcare innovation, we have yet to narrow health disparities gaps and sustainably improve health outcomes in Medicaid populations.

First, we have not embraced and solved for trust as a primary driver of healthcare decisions. Many beneficiaries perceived their healthcare encounters as condescending and disrespectful and believed these attitudes were due to their Medicaid coverage. A woman told me, “Well you know if you have Medicaid, they won’t give you the best treatment or the best doctors.” Furthermore, many people have shared their belief that doctors overprescribe medication and have a profit motive for doing so. Whether true or not, these perceptions about care drive behavior, and they should not be dismissed.

Second, distrust is potentiated by low health literacy. Unanimously, people felt healthcare language was too complex and poorly understood, causing them to turn to online searches, friends, and family members to obtain information. A Medicaid beneficiary told me, “If I don’t understand you, I don’t trust you.” Also, health literacy has been spoken about as a patient deficit rather than a provider and healthcare system responsibility. Failure to communicate and explain health information in tailored, plain language further erodes trust, exacerbates fear of the healthcare system, and discourages engagement in care. 

the healthcare system and providers are often perceived as paternalistic.
A beneficiary said his preference for the ER over a primary care doctor was because visits to a doctor made him feel ashamed. He described feeling berated by his doctor for not following instructions, and this was less likely to happen in the ER. He said, “The ER is all about the business. They don’t have time for that.”

Finally, the healthcare system is missing opportunities to improve digital engagement. Nearly every person I interviewed spoke to me using a mobile phone. However, health tech innovations built for Medicaid populations have been sluggish due to a belief the innovation will magically trickle down and blanket all populations. Furthermore, the narratives about the digital divide should be adjusted to reflect the reality of tech access among Medicaid beneficiaries, both in cities as well as rural areas. There is a perception that underserved communities are less tech savvy and often unable to engage in digital health solutions. But they are considerably engaged with smartphones - which are also computers - only not for health. The pandemic highlighted the ability to improve digital health access, and it is imperative this momentum continues in order to implement strategies to sustain and expand these gains.

Ultimately, these conversations and hundreds like them in the community compelled me to launch Grapevine Health. Grapevine Health is a social impact, for-profit, patient engagement company that leverages listening and trusted messengers to deliver tailored, culturally-appropriate, digital content to help people navigate their health. And it is working.

The pandemic afforded our company an opportunity to demonstrate the impact of the delivery of tailored, culturally-appropriate health information. We spoke to people who had previously refused the COVID-19 vaccine and were able to achieve vaccine acceptance rates of 30-70% among those engaging with a Grapevine Health expert.

Now we have shifted our attention to chronic health conditions like diabetes, a preventable condition that accrues over $300 billion annually in healthcare costs.

It is early, but we are seeing similarly positive signals, with a 150% increase in engagement from baseline.

The path we are on is somewhat non-traditional for a healthcare business, but we will continue listening and be guided by beneficiaries and the community. We need their voices and insight to tailor our solutions. We need to listen because, after all, they know far better than we do what it takes to improve their health outcomes.

Contact Lisa at: [email protected]