Unifying Outpatient Practices to Redress Structural Racism in an Urban Health System

There is a strong and increasing focus on redressing structural racism in health care systems. Structural racism persists by separating clinical care sites that treat patients of racial and ethnic minority groups who are disproportionately covered by Medicaid from sites that treat patients who are White and disproportionately covered by commercial insurance. Practice unification refers to efforts to eliminate this form of segregation.

To define and investigate the facilitators, barriers, and the effects associated with unification of outpatient practices to reduce structural racism in a large urban health system.

This qualitative study used semistructured interviews conducted within a large urban health system in New York from February to October 2023. Trained researchers interviewed clinical and administrative leaders of outpatient clinical practices that were pursuing unification, and health system leaders overseeing multiple practices.

Thematic analysis was used to identify facilitators of and barriers to unification, challenges and benefits after unification, and persistent dimensions of segregation within clinics that had nominally unified. These insights were used to create a framework for the unification process.

The thematic analysis included qualitative information from 5 administrative leaders, 12 clinical leaders, and 6 health system leaders, and found that unification facilitators were financial benefit, relocation to new facility spaces, and advocacy by leaders and trainees, while barriers were financial concerns, space constraints, and physician and staff attitudes. After attaining and experiencing some degree of practice unification, interviewees reported financial gain, more support staff, perceptions of greater equity, better educational experiences, and increased practitioner and trainee satisfaction. Challenges reported after unification were changes in staff roles, financial concerns, patient dissatisfaction, and difficulties interfacing with segregated practices within the health system. Partially unified practices maintained dimensions of segregation, by practitioner, payer, and/or scheduling/time (temporal segregation).

This qualitative study found that outpatient practice unification was perceived to be a financially and equity-driven process with multiple dimensions. However, not all of the unification procedures had been completely implemented. These findings indicate that successful unification of outpatient practices in a large urban health care system requires attention to multiple dimensions, as well as overcoming challenges regarding finances, facility space, reimbursement policies, and patient and staff satisfaction.