Equity Rx: Boston Medical Center's Work to Accelerate Racial Health Justice : Frontiers of Health Services Management

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Equity Rx: Boston Medical Center's Work to Accelerate Racial Health Justice

Walsh, Kate

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Frontiers of Health Services Management: Winter 2022 - Volume 39 - Issue 2 - p 4-16
doi: 10.1097/HAP.0000000000000158
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Daily, doctors type up prescriptions and send their ailing patients to the pharmacy. But for healthcare systems serving majority Black, Hispanic, Latino/a, Indigenous, and Asian populations from disinvested communities, the cure for what ails cannot be found at a pharmacy. Despite decades of advancements in clinical care, health inequities persist across the nation.

For us at Boston Medical Center (BMC), New England's largest safety-net hospital and the primary teaching affiliate for the Boston University School of Medicine, these disparities are deeply troubling. About two-thirds of our patient population identify with a marginalized racial or ethnic group. They are also frequently entrenched in racist systems that impede wealth creation. More than 60 percent of our patient population receives public insurance; approximately half have a household income below the federal poverty level. We see the health impact on our patients as they struggle with low-wage jobs, food deserts, and substandard housing.

For decades, all of us at BMC have taken pride in our leading work to “think beyond the pill bottle” by instead prescribing solutions to address the upstream drivers of poor health, from nourishing food to stable housing. Since its first prescription in 2001, our Preventive Food Pantry has grown to provide healthy groceries to 7,500 patients and their families each month. And because housing instability is a driver of adverse health outcomes, we began coordinating with community partners to help medically complex families obtain housing in 2016, an initiative that has reduced rates of poor health in children (Bovell-Ammon et al. 2020).

Building on these innovations, we have continued to lead. We prioritized economic mobility by helping patients collect tax refunds and open 529 college savings plan accounts at the doctor's office. We embarked on multi-institutional job creation and training projects that create pathways to career ladders. While these initiatives improved many lives, the horrific events that spurred America's reckoning on race in 2020, coupled with COVID-19's disproportionate devastation on the nation's communities of color, revealed that our actions were not delivering equitable care fast enough.

At the height of the pandemic in Boston, Black residents were 1.6 times more likely than White residents to die from COVID-19; Latino/a residents bore more than double the burden of infections than non-Latinos/as. Looking at health data beyond the pandemic, we found Boston's communities of color had health outcomes consistently 1.5 to 3 times worse than their non-Latino/a–White counterparts in Boston. Even when controlling for economic status, racial differences persist in outcomes such as pregnancy-related deaths, premature cancer mortality, and mental health (Boston Medical Center 2021). Uncovering these statistics in a city renowned for its healthcare and research institutions—at an institution with a long-standing commitment to exceptional care without exception—we realized our efforts to improve health for all patients were insufficient. Helping patients maintain their health is core to every hospital's mission, and to do that job it is essential to rethink how health systems address race.

At BMC, we believe health system leaders must hold themselves accountable, uncover the racism entrenched in societal systems and healthcare policies, and shift efforts from simply filling gaps to eliminating them. We need to be explicit about what it will take to meet the needs of the moment. Transforming healthcare in such a profound, fundamental manner requires humility to investigate and question what we think we know, focus to give this work sustained priority, and resources to fund the necessary restructuring of operations.

Unfortunately, the hospitals that serve Black, Indigenous, and people of color (BIPOC) populations also tend to be the least resourced. Like BMC, they are safety-net hospitals serving primarily Medicaid or uninsured patients whose reimbursement rates are much lower than the rates for commercially insured patients. Nevertheless, safety-net hospitals need to make the additional investments that are required to deliver equitable care. Building a budget that can sustainably fund an equitable healthcare system must be a priority. This work can take many forms such as assuming more risk, fundraising through philanthropy and grants to propel innovation, and advocating with public and private payers for reimbursement models that support the investment needed to reduce inequities.

To transform the care at BMC, we sharply focused our lens on race and ethnicity across the health system. We created multidisciplinary working groups to interrogate clinical operations; identify high-inequity clinical areas; explore the impact of health-related social needs; and investigate how racism factors into our research, education, and workplace culture. These working groups have captured the patient and community voice in multiple surveys for each initiative, interviews, and community dialogues in partnership with a community advisory board.

The result of this work is our Health Equity Accelerator, a transformative approach to target the root causes of race-based health disparities, promote and sustain economic mobility, and end health inequities (Exhibit 1). The accelerator is a new kind of prescription, one that is not handed to our patients but instead handed internally to all leaders, staff members, nurses, physicians, and researchers throughout the health system.

Heath Equity Accelerator's First-Year Core Enablers and Multidisciplinary Teams

Accelerating Improvement in Health Outcomes

The task at hand for BMC, as part of a mission-driven integrated health system, is to improve outcomes for the Black, Hispanic, and Latino/a patients (comprising our majority patient population) in five key clinical areas with the most significant health inequities: pregnancy, infectious diseases (including COVID-19), chronic diseases (primarily diabetes and hypertension), behavioral health (mental health and substance use disorders [SUDs]), and cancer and end-stage renal disease.

The organizational structure of the Health Equity Accelerator is the key to its effectiveness (Exhibit 2). At our academic medical center, we bring together investigators, clinicians, and experts from every facet of the system. These teams—one built for each of the five key clinical areas—form the heart of the Health Equity Accelerator.

EXHIBIT 2. - Example of Health Equity Accelerator Multidisciplinary Organizational Structure (Diabetes)
Senior leaders
Executive codirectors
Vice president of community engagement and external affairs
Priority clinical area team members (diabetes example) Role
Clinical decision-makers Medical director
Community health center medical director
Clinical experts Clinical lead
Nursing lead
Research experts Researchers
Research methodology expert
Medical librarian
Data analytics expert
Operational experts Clinical operations representative
Social needs expert
Patient navigator
Human resources/culture expert
Health equity experts Program manager
Strategy/learning health system expert
Community engagement expert
Patient engagement expert

Three institutional leaders direct the teams. Each leader brings a critical perspective to the work, including expertise in the principles of health equity, community engagement, and strategy. They ensure that initiatives align with institutional mission and community needs.

The clinical area teams meet biweekly to investigate inequities in the practices. As the team moves from discovery to implementation, more experts are added to the core team to help carry out solutions. Our analytics team leverages clinical and claims data plus data from our survey of patient needs and other external public health data points to uncover racial and ethnic trends and relationships that may not be obvious.

With everyone at the table, we generate hypotheses through primary research (extensive surveys, interviews, focus groups with patients) and existing literature.

Five Principles That Perpetuate Inequity

Rapid action to holistically address the inequities we uncover is paramount to our approach to equitable care. In developing the Health Equity Accelerator, we have learned five principles that apply to all clinical areas and disproportionally affect patients in marginalized communities by perpetuating cycles of health inequities. These principles are informing our prescriptions to align the goals of our established work to close health gaps. These principles, described in the following sections, can be guideposts for other institutions undertaking health equity work.

Wealth Is Health

Centuries of discriminatory policies (e.g., redlining) have raised significant barriers to a life trajectory of thriving in communities of color, limiting access to jobs, housing, education, and pathways to wealth building. A groundbreaking report (Muñoz et al. 2015) revealed a staggering divide: Black families in Boston had a median net worth of only $8 compared to $247,000 for White Bostonians. To break the generational cycles of poverty and poor health, we are embracing the power of BMC's role as an anchor institution to support the community with initiatives like StreetCred (described in the Sidebar).

Creating Living Wage Jobs and Career Pathways

BMC is part of an integrated health system that employs approximately 10,000 people. We recognize our leading role in improving economic development in the communities we serve. In 2017, we became the first hospital to participate in the BostonHires program, a city-led movement to connect residents to employment opportunities. As a partner with other anchor institutions and community organizations, we apply a place-based approach to recruit, train, and employ people from historically underinvested neighborhoods surrounding our campus. A grant from JPMorgan Chase as a part of its Advancing Cities Challenge has enabled us to hire more than 600 people from the community.

In addition, we are working to fast-track career advancement for employees of color within our health system through a six-month leadership acceleration program. The training program connects top-performing employees with career coaches, mentors, and career navigators to help them transition into management roles in our health system. We recently completed our fourth cohort of the program.

StreetCred: Building Wealth to Improve Health

In 2016, a mother's request for tax preparation help in the BMC pediatric waiting room sparked an innovative solution to put money back into the pockets of families who cannot afford to lose it. Two BMC pediatricians who heard about the mother's request for help were moved to develop StreetCred, a free in-hospital tax preparation service that now returns nearly $1 million annually to Boston families (www.mystreetcred.org).

StreetCred exemplifies the holistic way BMC targets the social ills of poverty, housing instability, and hunger—the main drivers of poor health that cannot always be addressed clinically.

For example, the federal earned income tax credit (EITC) and expanded child tax credit can provide an average of $2,000–$3,000 a year to eligible low- to middle-income families, which is enough for about six months of groceries. Yet many families (like those led by the young mother in the BMC pediatric waiting room) are unable to claim their EITC on their own and must find hundreds of dollars to pay for the services of a professional tax preparer.

The Health Equity Accelerator has prioritized the expansion of StreetCred's bundled-model approach, which systematically offers financial coaching and enrollment support for 529 college savings plan accounts, in addition to tax preparation. Together, the services foster financial literacy and wealth building. StreetCred. which is now offered in nine states and Washington, DC, recently launched the Medical Tax Collaborative (MTC) to build a wider movement toward incorporating financial well-being into healthcare. The MTC provides technical support to hospitals and health clinics that want to launch their own medical–financial partnership programs.

Partnering With BIPOC Business Owners

BMC spends $2 billion annually on supplies and services, and we are working to ensure equity when sourcing and purchasing from these vendors. Our supply chain department operationalizes an intentionality to purchase from women- and minority-owned vendors. We report on the data monthly to an internal committee that monitors progress.

Improving Health Through Affordable Housing

Better housing is preventive medicine at its best. Since 2017, BMC has invested $6.5 million to improve community health with more affordable, supportive, and stable housing. For example, in 2017 BMC launched a collaboration with Boston Children's Hospital and Brigham and Women's Hospital to identify, assess, and fund strategic approaches to increase housing stability for vulnerable populations. BMC also invested in an affordable housing development that has committed to providing 60 supportive housing units for individuals with complex medical needs.

These investments have been funded in part through the Massachusetts Determination of Need (DoN) process. Health systems that undertake campus renovations are required to direct a portion of the cost into investments in community projects. In 2017, during our campus consolidation, we allocated our DoN funding obligation to increase Boston's inventory of supportive housing units.

Investing in Neighborhood Economies

To build a strong ecosystem of inclusive wealth building and economic mobility, BMC is investing in local BIPOC businesses to grow and hire locally. For example, as part of our DoN obligation, we provided a $1 million no-interest loan to a supermarket in a new affordable housing complex in the Roxbury neighborhood. The full-service halal market provides fresh produce and food to a community with few accessible grocery chain options. With the loan, we advocated for the operators to be owners of the business and the physical space. We also advocated for living-wage salaries for the employees and for employee equity ownership in the business.

Time Is a Luxury

Disease prevention and health management can take the time that BIPOC populations do not have. A survey found that 64 percent of Black children live in single-parent households (Annie E. Casey Foundation 2022), and many of these parents work multiple jobs or shifts that leave few hours to prioritize healthcare. A doctor's visit means taking a half day or more off from work; a diagnosis may require multiple clinical visits and long processes with insurance companies to qualify for treatment. Chronic conditions such as diabetes and hypertension present special challenges for patients who cannot closely monitor their disease or take off work for appointments.

Missed routine care, screenings, and delays in procedures are disproportionately costing Black and brown patients and leading to worse health outcomes. The Health Equity Accelerator is forging new pathways to reduce the time required for patients to invest in their health. In times of crisis, this means meeting patients where they are. In day-to-day clinical practice, it means pinpointing how we can make care more convenient and better streamlined for our patients. Some examples follow:

  • Expanded access to care. In 2020, BMC cared for consecutive surges of the sickest COVID-19 patients in greater Boston—not surprising, given that many people in the communities we serve are essential workers who cannot shelter in place and live in crowded, multigenerational households. When the vaccine first became available, we quickly recognized the emerging “vaccine access desert” in these hard-hit communities. We partnered with community organizations and government agencies to stand up five vaccination sites at our community healthcare centers early in the rollout. We made sure there was a vaccination site within a mile of everyone in our catchment area. Beyond that, we added a mobile unit that has held more than 400 pop-up vaccination events as a partner with Boston Public Schools and YMCAs in areas with high concentrations of unvaccinated patients. This inclusive approach increased equity in vaccine distribution. As of September 2022, 63 percent of patients vaccinated at BMC and our community vaccination sites have been people of color, compared with 31 percent of people of color vaccinated throughout Massachusetts.
  • Innovation through new time-saving technology. Many of BMC's excess cases of severe maternal morbidity among Black patients have been the result of variations in the management of preeclampsia. To address this, our obstetrics and gynecology department is launching interventions to build patient agency around preeclampsia (e.g., doula expansion, multicultural preeclampsia education, a website chatbot), tighten protocols to reduce variation in timing, retrain staff to better partner with patients in decision-making, and provide remote blood pressure cuffs to high-risk pregnant patients. The technology enables nurses and physicians to identify serious changes in blood pressure earlier while expectant and new mothers stay at home. The intervention is showing promising results with high patient engagement—the rate of any hypertension-identified postpartum for the first 1,000 patients using devices was 64 percent, double the rate reported in other studies (Mujic, Parker, and Yarrington 2022). Similar studies are underway using cellular glucometers to remotely monitor patients who are at risk for gestational diabetes.

Agency Is Essential

When patients feel that a healthcare decision or procedure is done to them, not for them, they lose a sense of safety and trust in the system. This loss can affect future patient–provider communication and result in delays and differences in care.

Mistrust of the health system will endure until a more culturally adept and relatable approach is found. The Health Equity Accelerator team has identified a three-pronged approach to the problem.

Bolster Cultural Responsiveness

We are working to be a trusted resource that aligns culturally with patients' information needs and empowers them in complex health situations where there is a lot to learn. Beyond enriching the BMC healthcare team's ability to empower patients across healthcare settings, we are providing more culturally and linguistically inclusive patient support.

For example, we found vast disparities in severe maternal morbidity between Black and White pregnant patients. As part of our response, we expanded our Birth Sisters program, which offers women “sisterlike” doula support during pregnancy and through the postpartum period. Our multicultural doulas have improved birth outcomes, breastfeeding rates, and the experience of care (as indicated in patient surveys). Black patients with birth sisters have fewer cesarean sections and more exclusive breastfeeding during delivery hospitalization compared to Black patients without birth sisters, and patients (regardless of race) with birth sisters have babies at a higher gestational age at birth and fewer neonatal intensive care unit admissions compared to patients without birth sisters. With this encouraging data and grant-funded support, BMC is hiring and training more women from the community to expand the doula service.

Confront Racism in the Workforce

Confronting implicit and explicit bias and racist attitudes within the healthcare workforce is essential to transform care. Working hard to implant diversity, equity, and inclusion (DEI) into the organizational DNA at BMC, we have created and embedded a culture code. The code includes basic behaviors for everyday encounters, such as “Make it a 5-star hello” and “S.T.O.P (See The Other Person),” to help staff authentically engage, set aside snap judgments, and incorporate DEI into all interactions. We are conducting training that includes this new framework as well as many tools for intervention throughout the campus to help teams grow in self-awareness and deliver excellence.

Ensure Representation in Medicine

Commitments to equity, engagement, and cultural representation at all levels and patient touchpoints are essential to building patient trust. We take this seriously in multiple ways at BMC, from unique advancement programs that increase diversity in our hospital workforce and leadership to boosting recruitment efforts of underrepresented in medicine (URiM) trainees in residency and fellowship programs.

Academic medical centers play a crucial role in supporting the matriculation and career development of medical students of color. Nationally, only 13 percent of active US clinical residents self-identify as Black or Hispanic (Accreditation Council for Graduate Medical Education 2021), which means that they are URiM. Despite BMC's diverse patient population, the racial diversity of our residency training programs has historically been equal to or less than the national median (Wusu et al. 2019). To grow a more diverse physician workforce, we set a goal of at least 20 percent of URiM residents and fellows. In the 2022 academic year, we recruited the highest percentage of URiM intern classes ever at 29 percent, and the highest number of overall URiM trainees (residents and fellows) at 21 percent.

Timing Is Everything

In studying racial inequities, the Health Equity Accelerator team found mounting evidence that inequities in outcomes stem more frequently from differences in the timing of care than from differences in the quality of care. For example, many excess cases of severe maternal morbidity among Black patients at BMC resulted from variations in the management of preeclampsia, as described earlier. Delays in diagnosis or treatment result in an increased risk of complications and mortality.

We have determined that when there is no clear goal on how long something should take, it takes longer for BIPOC patients. From diagnoses to the start of treatment, ambiguity in process breeds discrimination. Tightening protocols is the quickest, most impactful way to reduce disparities in health outcomes. BMC departments are now expected to review decisions that are time sensitive and set standardized goals for the timing of those decisions.

Rethinking Decision to Incision

As part of BMC's quality improvement work in 2019, we uncovered the fact that our Black patients were waiting significantly longer for urgent cesarean sections than our White patients. In response, we created a decision-to-incision metric for the department. Standardization of this protocol helped to address process bias and worked to reduce the time disparity between Black and White patients substantially (Mendez-Escobar et al. 2022).

Dialing in on Our Approach to Diabetes

We are also stressing the importance of timing in our Equity in Diabetes initiative. We have learned how delays in treatment may contribute to inequities in diabetes management. A national study reported that only 10.4 percent of patients with a diagnosis of prediabetes had a coded diagnosis of prediabetes, only 1.0 percent were referred for nutrition, and only 5.4 percent were prescribed metformin despite clinical practice guidelines to do so. Further, Black individuals were 1.4 times more likely to develop diabetes than White individuals (Tseng et al. 2022). The Health Equity Accelerator team is working to understand and apply tighter protocols of prediabetes management in primary care at BMC.

Averages Are Blind

Many national guidelines and beliefs in medicine are based on population averages that do not apply to all subgroups, and we at BMC have long known that our BIPOC patients face unique health challenges. In building the Health Equity Accelerator, we addressed the need to systematically identify what matters to BIPOC patients to a disproportionately greater degree than national averages, and we continue to specialize our care to improve their outcomes. We acknowledge and embrace race as part of health.

Promoting Excellence in Sickle Cell Disease Care

In a US population of nearly 330 million, sickle cell disease is typically classified as rare. Drilling down, however, 1 in 13 Black Americans carry the sickle cell trait, making the incidence of the disease much higher in predominantly Black communities. Many health systems still lack protocols to care for patients with sickle cell disease who come to the hospital in excruciating pain. Long wait times, inadequate care, and continued discrimination serve to perpetuate poor health outcomes and reduce life expectancy. Through BMC's Center of Excellence in Sickle Cell Disease, we have created, and continue to expand, models of care and protocols that ensure proper multispecialty care from birth through adulthood for patients and expedite pain management for patients who are experiencing acute sickle cell crises.

Prioritizing Prostate Cancer

Frequently, cancer screening projects deprioritize prostate cancer because, generally, it can be well managed and has a low mortality rate. That may be true on average, but for Black men, the death rate of prostate cancer is more than two times higher than for white men (American Cancer Society 2022). With a dedicated multicultural outreach team, we are launching an effort to increase cancer screening rates.

Expanding Treatment Options for SUD

BMC is at the forefront of addiction care. We pioneered office-based addiction treatment, now the key to nationally scaled opioid addiction treatment in primary care. Working to quell the opioid crisis with medications has been top priority.

However, we found that 67 percent of our Black patients have SUDs unrelated to opioids and therefore need different treatment options. Although more than 90 percent of patients with opioid use disorder are engaged in outpatient treatment, this number is much smaller for patients with other SUDs. Over the past two years, we have expanded psychotherapy (the most effective outpatient option for nonopioid SUDs) and other treatment options to close disparities in care. To provide more equitable care, we recently opened an 82-bed inpatient care facility in Brockton, Massachusetts. The new facility cares for co-occurring psychiatric and SUD disorders and addresses a critical shortage of behavioral health inpatient beds. The new facility is a pivotal resource to help our patients with SUD toward long-term recovery.


Launching the Health Equity Accelerator has been a humbling and clarifying experience at BMC. We embrace our role, both inside our organization and outside our walls, as a community leader in rethinking the delivery of care. The stakes are high. With unflinching focus, strong partnerships, and investment priorities, we have defined the work ahead that is required to address inequities. Using five principles as guideposts—wealth is health, time is a luxury, agency is essential, timing is everything, and averages are blind—we created a prescription that we believe can also catalyze change at other healthcare organizations.

As communities continue to grow in diversity, the health systems that serve them must also evolve and relinquish antiquated one-size-fits-all approaches to care. Race is part of health, and care systems must embrace and address that reality. By adopting that social obligation, we at BMC are expanding our efforts to help wipe out appalling health disparities so that all patients can live healthy lives.

Lown Institute: Measuring What Matters

More and more hospitals are walking the talk when it comes to social responsibility. Their forward movement is driven by new methods for measuring hospital performance to which they can be held accountable. It's a challenging but exciting time for the healthcare sector.

How can this evolving movement be scaled up? By analyzing big data across 54 different metrics and publishing the results, the Lown Institute is working to raise the standard for hospital social responsibility.

Hospitals are uniquely positioned to lead on social responsibility because of the multiple roles they serve within their communities. They are not only healthcare providers but also employers, purchasers, political actors, and part of the physical environment of their neighborhoods. The decisions hospital leaders make—how they invest in local health initiatives and community organizations, who they welcome into the hospital and onto their board, and how much they pay their workers—have a great impact on the well-being of their community.

When hospitals build community health programs around housing, education, and food security, they can improve health from earliest childhood. Ensuring that care is accessible to all regardless of income, race, ethnicity, or insurance status helps reduce healthcare disparities. And paying employees fairly boosts financial security in the community, which benefits both health outcomes and local economic vitality.

The growth of environmental, social, and governance (ESG) products in the financial sector has propelled the movement further. More than $50 billion flowed into sustainable funds in 2020, nearly 10 times the amount just 2 years prior (Hale 2021). At the same time, conflicting definitions of ESG and concerns about greenwashing (businesses using marketing to burnish their image without making any real change) have led to scrutiny and regulatory action. The Securities and Exchange Commission will be adopting new standards for ESG disclosures for publicly traded companies to ensure that they include “material, decision-useful” information on ESG (Lee 2022). As the ESG movement continues, access to metrics that are clear, meaningful, and trustworthy is increasingly important.

Hospitals that have made commitments to confront racism in their institutions, reduce health disparities in their communities, and invest in programs to improve social drivers of health need to ensure that these sentiments translate into accountable action. The Lown Hospitals Index for Social Responsibility (www.lownhospitalsindex.org) evaluates 54 measures across equity, value, and outcomes to help hospital leaders track progress on social responsibility and identify opportunities for improvement (Exhibit 3). Besides setting ambitious goals for the sector, the index honors the hospitals that are leading the movement toward social responsibility with top grades.

The Lown Hospitals Index Tree

Index metrics include:

  • inclusivity, which measures how well a hospital's patient population reflects the racial and socioeconomic demographics of the community surrounding it;
  • community benefit, which measures investments with direct local impact by reporting on hospital spending on financial assistance and community health investments, as well as hospitals' service of Medicaid patients; and
  • pay equity, which measures how much hospitals' senior executives are compensated compared to hospital workers without advanced degrees.

The results of the Lown Hospitals Index also illuminate systemic barriers to health equity. For example, many major metro areas in the United States have racially segregated hospital systems, driven in part by a reimbursement system that pays less for publicly insured patients compared to privately insured ones (Garber 2022). Similarly, the lack of regulations on community benefit allows some hospitals to give back much less than others. Through its reports, convenings, and partnerships, the Lown Institute arms hospitals and policymakers with the data needed to align financial and regulatory incentives toward social responsibility.

For Lown Institute founder Bernard Lown, MD, it wasn't enough for doctors to care for their patients. He believed that they also had to advocate for the health of humanity. Since the Lown Hospitals Index was launched in 2020, many hospitals have embraced Dr. Lown's expansive vision of the role of medicine by building social responsibility into their goals and sharing their performance along the way. In this way, hospitals can be not just providers of high-quality care but also champions for equity and contributors to community well-being. They know it's not enough to do no harm, they also know that they must strive to do good.

Lown Institute


    Thea James, MD, executive director of the Health Equity Accelerator and vice president of mission and associate CMO at Boston Medical Center Health System, and Elena Mendez-Escobar, PhD, executive director of the Health Equity Accelerator and executive director, strategy, at Boston Medical Center Health System made significant contributions to this article.


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    © 2022 Foundation of the American College of Healthcare Executives