How does the health equity ecosystem move from awareness to action?

Authors
Susan Garfield, DrPH

EY Americas Chief Public Health Officer and Global Client Service Partner

Health and life sciences strategist. Helps companies transform businesses and leverage technologies. Public health leader. Addresses health equity issues and builds better public health resilience.

Yele Aluko MD, MBA

EY Americas Chief Medical Officer

Proven MD/MBA physician executive and corporate leader with astute clinical and business healthcare industry expertise and insight.

Belinda Minta

EY US Public Health Services Transformation Leader

MPH and MBA; collaborating with clients to transform and help optimize public health services; a public health professional; focuses on working with clients to Prevent. Promote. Protect.

Christine Hildreth

Manager, Health Sciences and Wellness, Ernst & Young LLP

Ardent health sector professional. Passionate about enabling innovative, equitable approaches across health and life sciences. Avid cook. Road trip enthusiast.

Perri Kasen

Senior Manager, Consulting, Ernst & Young LLP

Health equity strategist; diversity, equity and inclusion advocate; and social impact consultant with over a decade of experience. Works to realize vision of equitable experience and outcomes for all.

17 minute read 9 Jan 2023

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  • 2023 Health Equity Outlook Report (pdf)

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Inaugural Health Equity Outlook Report highlights EY Center for Health Equity survey findings for potential cross-sector collaboration to drive alignment and impact.

In brief

  • Five hundred health equity leaders were surveyed across provider, payer, public health, life sciences, and nonprofit and community organizations.
  • More than half of all health equity strategies are led by a chief health equity officer; 34% of these strategies were initiated during the COVID-19 pandemic.
  • High variation in health equity priorities: No more than 20% of organizations indicated any given focus area is their No. 1 priority.

While US health disparities have been the focus of remediation efforts for decades, COVID-19 created shared urgency and a common language for all to understand their extent and impact on a national stage. Health inequities are the cumulative result of a biased system, the lived experiences of diverse individuals and the challenging environments that impact all dimensions of people’s lives.

Health equity is an aspirational goal whereby all people experience similar health outcomes regardless of race, ethnicity, socioeconomic status, education, neighborhood or other potentially disadvantaging social and structural determinants of health. Progress is challenged by systemic drivers that are rooted in a history of overt and covert bias in US society, and by extension, in US medicine.

Health equity has become an organizational priority for many sectors across the health value chain. Understanding how other organizations are approaching health equity within and across sectors can provide important learnings for peers seeking to drive impact on outcomes and delivery. No single organization can solve the issue on its own. Health equity initiatives necessitate collaborative coordinated action underpinned by strategic intent and measurable outcomes.

The inaugural EY Center for Health Equity Annual Survey provides insights into how organizations are addressing the challenge of overcoming health disparities and driving toward health equity goals. It sheds light on current health equity objectives, priorities, barriers, and where leaders see the field moving from here.

To capture these insights, Ernst & Young LLP (EY US) surveyed 500 leaders across provider, payer, public health, life sciences, not-for-profit and community organizations who are responsible for developing or executing efforts related to health equity or disparities within their organizations. The survey specifically explored six areas critical to organizational health equity impact:

  • Health equity strategy
  • Data and analytics
  • Diversity, equity and inclusion (DEI)
  • Education
  • Clinical research
  • Community engagement and ecosystem partnerships

Overall findings

The inaugural EY Center for Health Equity Annual Survey demonstrated strong cross-sector momentum in the health equity space. Provider, payer, public health, life sciences, not-for-profit and community organizations are developing strategies, investing in a diverse set of health equity-oriented priorities and building an infrastructure to drive efforts.

Surveyed organizations are tackling health equity from multiple angles — creating opportunities for broad impact. A lack of cohesive industry priorities also runs the potential risk of spreading resources thin and inhibiting targeted collective action. Variance reported in how organizations have designed their health equity strategies also suggests an opportunity for further ecosystem alignment on the most promising approaches and key actions needed to make progress.

The following report will provide detailed insights on findings across each of the six areas of exploration. Select findings below illustrate the observed current state and direction of health equity activities across the market.

Chart 1. Overview of key survey findings, including total number of survey participants by organization type, percentage of health equity strategies started during COVID-19 (within the past three years), top health equity priority across the market and top barrier to health equity strategy development across the market.

Figure 1
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    An overview of key survey findings indicated that health care access and quality was the top health equity priority across the market (20% of surveyed organizations) and that a “lack of common understanding or awareness of what health equity entails” was the top barrier to health equity strategy development across the market (19% of surveyed organizations).

    A pie chart shows total number of survey participants by organization type: provider (119), nonprofits and community organizations (112), life sciences (100), payer (100) and public health (69).

    A pie chart shows when health equity strategies were initiated: 34% were started during COVID-19 (within the past three years), 20% four years ago, 5% five years ago and 41% more than five years ago.

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Chapter 1

Strategy

A well-defined health equity strategy sets the stage for organizational commitment and progress.

Advancing health equity should start with strategy. Regardless of where an organization is along its health equity journey, an enterprise-level approach is core to defining strategic goals, prioritizing initiatives and creating alignment among leaders. The strategy, once developed, can be the foundation for how health equity priorities are then translated into programs, funding and collaborations, and how health equity principles are embedded in an organization’s people, processes, technology and key performance indicators (KPIs). Health equity strategies will also evolve over time as programs mature, the external landscape changes or the organization’s priorities shift.

Without a defined strategy, ownership and accountability, health equity runs the risk of remaining an aspirational goal vs. becoming a structured program with operational viability and resources. Encouragingly, 98% of surveyed organizations report having a health equity strategy in place and 82% report that strategy as being enterprise-driven. A noted caveat is that eligibility to participate in the survey was intentionally contingent on respondents having a role in health equity efforts, inherently increasing the likelihood of participants coming from organizations with defined strategies.

To lead this strategy, 58% of organizations have designated a chief health equity officer (CHEO), 21% have enveloped it into the responsibilities of another C-suite or comparable executive-level leader and 20% have established a health equity director. Life sciences organizations in particular skew toward designating a CHEO (79%).

Health equity is, however, a relatively new endeavor for most respondents. Roughly 60% of organizations developed their health equity strategy within the past five years — and 34% within the past three years, largely during the COVID-19 pandemic. Inversely, governments have been active in the space for much longer: 62% of state public health agencies have had a strategy in place for over five years. Regionally speaking, both newer and more enterprise-driven strategies are found in Northeast-based organizations.

When asked their top three health equity priorities, organizations indicated the greatest consensus on three key areas but otherwise ranked most priority areas similarly:

  • Health care access and quality (34% of all organizations)
  • Health equity strategy development (33% of organizations)
  • Diversity and inclusion of employees (28% of organizations)

Chart 2. “Which of the following are your organization’s top three health equity priority focus areas?” | Survey responses for all organizations and an indication of each organization type’s top three priority focus areas.

Figure 2
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    A bar chart shows frequency of survey responses to the question “Which of the following are your organization’s top three health equity priority focus areas,” including an indication of each organization type’s top three priority focus areas.

    Health care access and quality (34%), health equity strategy development (33%) and diversity and inclusion of employees (28%) were the top three priorities across all surveyed organizations.

Synergies in reported priorities offer intuitive opportunities for ecosystem partnerships. For instance, life sciences and public health organizations demonstrate shared interests in addressing clinical trial diversity and health care costs — and one benefit of a partnership between the two has already been realized from their collective efforts during the COVID-19 pandemic.

To determine priorities, community engagement, organizational values and state and local health authority data are the most common inputs but are used by less than half of surveyed organizations. No significant preferences are seen by organization type, creating potential opportunity for more standardized data inputs to strategy development across ecosystem participants. As strategies mature, correlations between inputs and impact may naturally elevate the relative criticality of drivers in ongoing strategy evolution.

No single barrier to strategy development stands out as having markedly higher impact across or within industries. Lack of a common understanding or awareness of what health equity entails, and lack of financial commitment are seen slightly more commonly as the top barrier to an organization (16%).

Chart 3. “Rank in order the top three barriers your organization faces most often when setting and implementing health equity goals and initiatives” | Survey responses for all organizations, and an indication of the top barrier by organization type.

Figure 3
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    A bar chart shows frequency of survey responses to the request “Rank in order the top three barriers your organization faces most often when setting and implementing health equity goals and initiatives,” including an indication of the top barrier by organization type.

    Lack of common understanding or awareness of what health equity entails (16%) and lack of financial commitment (16%) were the top two barriers across all surveyed organizations.

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Chapter 2

Data and analytics

Data and analytics are complementary contributors to realizing health equity priorities.

Ignited by emerging technologies, consumer-centric experiences and rapid clinical innovation, the world is entering an entirely new generation of data and analytics built on a flexible, agile and quickly evolving combination of technology, ecosystems and talent. In a few short years, data and analytics will drive and predict the most important decisions, processes and interactions of organizations. As we seek to transform among the industries that contribute to achieving health equity, data and analytics will be the foundation organizations and their leaders will use to inform, support and drive realization. 

For many organizations, health equity use cases represent a new frontier of data and analytic maturity. Early stages of maturity involve an organization involve focused data collection and analytic stratification efforts to identify health inequities. As organizations mature, those insights are used to inform strategic health equity priorities and quantitatively demonstrate equitable outcome achievement.

Organizations across maturity levels recognize the value of regularly reporting out on health equity metrics and KPIs: 70% of respondents share data updates with internal leadership as well as external stakeholders on a monthly or quarterly basis.

While most organizations surveyed have a health equity data and analytics strategy in place (85%) and have defined KPIs to track progress toward health equity goals (89%), there is variability in how data is being used to drive action across organization types. Providers, public health and community organizations are more frequently collecting and disaggregating data to identify inequities, while payers and life science organizations are more frequently utilizing data insights to define strategic priorities for health equity. Across all organization types, it is less common to use data and analytics to inform ongoing improvement of health equity initiatives. Of note, 10% of payers report they do not currently collect and analyze member utilization data to identify disparities and track inequities across their covered populations.

Chart 4. “What stage of building a health equity data and analytics suite of capabilities are you currently in now?” | Reported stage by organization type. Note: Horizontal lines indicate the average percentage of organizations in a given stage across all survey respondents.

Figure 4
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    A bar chart shows survey responses to the question “What stage of building a health equity data and analytics suite of capabilities are you currently in now,” by stage and organization type.

    Of all surveyed organizations, 31% are in Stage 1: Collection and stratification of data to identify health inequities, 48% are in Stage 2: Utilization of data insights to inform strategic priorities in health equity and 18% are in Stage 3: Driving improvement activities through health equity analytics.

Responding organizations are developing and leveraging multifaceted analytic capabilities, with approximately half of respondents across organization types making use of a mix of descriptive, diagnostic, predictive and prescriptive analytics as part of their health equity efforts. Specific areas that organizations reported investing in to develop their health data and analytic capabilities include use of genomic data, machine learning and technologies that enable interoperability and data privacy. However, significant foundational gaps remain: Only 47% of surveyed organizations said they had reliable health equity data reporting and insights or had taken steps to organize data to make the business case for health equity.

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Chapter 3

Diversity, equity and inclusion (DEI)

DEI initiatives directly correlate with opportunities to deliver successful health equity.

DEI initiatives have played a critical role in health care for over 20 years. In recent years, DEI has served as a launching pad for health equity. Health care organizations have come to recognize that workforce equity leads to patient equity and positive health care outcomes. Organizations that embed DEI within their company culture and ways of working are often better positioned to be successful in the delivery of health equity.

Roughly one-quarter (28%) of all surveyed organizations — and close to half (42%) of health systems and behavioral health organizations in particular — put DEI synergies at the forefront of their strategy, indicating diversity and inclusion of employees is their top priority in health equity. Health care organizations have a unique opportunity to address social determinants of health for their own employees, given they often play a dual role of both employer and health care provider — further solidifying DEI as an enabler of health equity.

Many of these efforts are structurally driven from a human resources-perspective, and nearly all organizations (96%) evaluate their practices and policies to ensure internal equity on at least an annual basis. Life sciences companies, nonprofits and community organizations, and organizations with a health equity strategy in place for over five years are most likely to conduct evaluations on at least a quarterly basis.

Chart 5. “How often does your organization evaluate its practices and policies to ensure internal equity within your organization, including employees and your suppliers?” | Frequency of evaluation by organization type.

Figure 5
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    A pie chart shows frequency of survey responses to the question “How often does your organization evaluate its practices and policies to ensure internal equity, including employees and your suppliers?”

    Life sciences organizations (47%), nonprofits and community organizations (43%) and organizations that have had a strategy in place for more than five years (41%) are most likely to evaluate practices and policies on at least a quarterly basis.

On average, 50% to 60% of organizations across the health value chain have also already implemented DEI initiatives such as councils, governance structures, education, employee resource groups or mentorship programs. Nearly all other organizations have these types of efforts planned. Payers and nonprofits and community organizations are more likely to be in the planning phase.

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Chapter 4

Health equity education

Efforts to broaden health equity education throughout the health value chain are invaluable.

Over the past two years, online searches for “health equity” have doubled¹ — reflecting both how COVID-19 raised awareness of health disparities and the movement of health equity discourse into the broader conversation. Within organizations attempting to address this space, there may be wide variability in knowledge of health equity among the workforce. As a result, opportunities for education exist around what healthy equity is, the root causes of inequities, the ecosystem involved in addressing them and the historic context.

On average, respondents report feeling their organization has a relatively high (7.7/10) understanding of health equity fundamentals and a similar level of understanding (7.5/10) of the organization’s health equity policies. However, the most common barrier reported for setting and implementing health equity goals is the lack of common understanding or awareness of what health equity entails — a top three barrier for 47% of organizations. This is further pronounced in roughly half (53%) of payer and nonprofit or community organizations. Of note, this remains the top barrier even for organizations that have had a health equity strategy in place for more than five years.

Chart 6. “Rank in order the top three barriers your organization faces most often when setting and implementing health equity goals and initiatives” | Frequency of “Lack of health equity understanding/awareness” identified as a top three barrier by organization type. Note: A dark bar indicates an organization type that identified this as its No. 1 barrier.

Figure 6
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    A bar chart shows frequency of survey responses to the request “Rank in order the top three barriers your organization faces most often when setting and implementing health equity goals and initiatives,” and the frequency of which “Lack of health equity understanding/awareness” was identified as a top three barrier for the organization-type.

    53% of payer, 52% of nonprofits and community organizations, 49% of public health, 47% of life sciences and 37% of provider respondents indicated this as a top three barrier. It is the number one barrier for nonprofits and community organizations.

Further, only 55% of organizations provide education to employees on health equity and disparities. Slightly more commonly, education is directed toward leadership — as seen in 60% of organizations.

Life sciences organizations — especially medical device companies — provide education at higher rates and to broad audiences, with ~60% of the sector nearly equally targeting leadership, employees and customers. Educating vendors or third-party partners is least common for the health value chain at-large, but health-focused nonprofits, medical device companies and state public health organizations have taken stronger action here.

Chart 7. “Which, if any, of the below groups does your organization currently educate on health equity and health disparities?” | Percentage of organizations providing education to each group by organization type.

Figure 7
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    A bar chart shows frequency of survey responses to the question “Which, if any, of the below groups does your organization currently educate on health equity and health disparities?” Across all surveyed organizations, leadership teams are most frequently educated on health equity and health disparities.

Direct employee engagement can provide transparency into how well health equity is understood throughout the organization, enable feedback on areas of interest and outstanding questions, and illuminate opportunities to tailor education to fill identified gaps — allowing for bidirectional learning and validation that outreach is meeting the needs of the target audience.

Employee engagement can similarly help validate that the organization’s health equity strategy, initiatives and metrics are communicated effectively internally.

Scientists analyze sample in petri dish
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Chapter 5

Clinical research

Addressing the need for diversity in clinical trials is a major step toward cohesive health equity.

Clinical research has historically underrepresented minorities, women and older people. To address health disparities and show evidence that therapeutics taken to market are efficacious in all populations, research needs to include the representative diversity of all societal demographics. Life sciences companies are recognizing this need, changing how they recruit and target trial participants, aligning with ecosystem stakeholders on clinical trial diversity imperatives and developing meaningful strategies and partnerships that build trust in communities. 

Across the end-to-end clinical trial lifecycle, health and life sciences organizations are pursuing diversity at every stage, but without consensus on a clear priority area within or across either industry.

Chart 8. “When it comes to health equity in R&D, using the choices below, rank in order the areas your organization is prioritizing most in the clinical trial diversity lifecycle.” | Survey responses for all organizations’ No. 1 priority area, and nuances by industry, age of strategy, and organizations that indicated clinical trial diversity as a top five health equity priority.

Figure 8
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    A bar chart shows frequency of survey responses to the request “When it comes to health equity in R&D, using the choices below, rank in order the areas your organization is prioritizing most in the clinical trial diversity lifecycle” and indicates response for all organizations’ number one priority area across patient engagement (16%), research prioritization (16%), inclusive protocol design (15%), patient recruitment (15%), patient retention (13%), diverse investigator pipeline (12%) and site identification/initiation (12%).

    When looking at top priorities by industry, 20% of life sciences organizations prioritize patient recruitment vs. 19% of providers prioritizing patient engagement. When looking at top priorities by age of strategy, 21% of organizations with strategies developed during the last three years prioritize protocol design vs. 18%-19% of organizations with strategies in place for over five years prioritizing patient recruitment, engagement and retention. Twenty-four percent of organizations with clinical trial diversity as a top five health equity priority prioritize inclusive protocol design and patient recruitment.

Every stage of the clinical trial lifecycle presents an opportunity to drive diversity, and it is a welcome development that the industry recognizes that value. Frayed approaches toward action have the potential to impede acceleration of progress, however, and industry alignment can enable the power of collaborative efforts.

Defining what these efforts will impact, of course, is central to their efficacy. Although most organizations have appropriately begun setting metrics to clinical trial diversity goals, 25% of providers and 15% of life sciences organizations have not yet identified KPIs. 

While public health organizations were not surveyed on their clinical research priorities at this time, they must be included in the discourse for future survey iterations given the relative prioritization they indicated for clinical trial diversity as seen in the results and discussed in the Strategy section. As organizations pursue impact across the clinical trial continuum, future survey iterations will also investigate what is found to be effective to improve diversity: Decentralized clinical trials? Pharmacy engagement? Impact of cross-industry collaborations between health and life sciences companies? Shared learnings will help guide health equity advancement in clinical research.

Adorable baby boy claps during medical exam
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Chapter 6

Community engagement and ecosystem partnership

Without collaboration, efforts to reach the overall goal of health equity will remain stagnant.

People are at the heart of driving health equity. Progress cannot be achieved within siloed environments like a corporate bubble, public agency, nonprofit organization, or via a technological innovation. Impacted communities need to be directly engaged in strategies and initiatives that aim to serve them. Further advancing health equity also cannot be actualized by one organization alone. Exponential power exists when ecosystem partnerships, public-private collaboration and joint ventures are activated to amplify organizational strengths in service of health equity. 

The value of community engagement is widely acknowledged across the health value chain, with nearly all (99%) health-related organizations intentionally involving community leaders, community-based organizations, and those with relevant lived experiences in their health equity efforts. Respondents report that the top three purposes behind engaging these groups are to (1) seek input on health equity program design and delivery, (2) seek input on health equity strategy development, and (3) share feedback with other entities on health equity issues. Organizations are deploying many approaches to engage communities where they are, ranging from awareness campaigns, community events, education and training opportunities, and community workgroups or task forces. Notably, nearly a third of all respondents are engaging with the community to cocreate their health equity strategy, with public health (38%), life sciences (35%) and payers (32%) leading the way relative to community (25%) and provider organizations (22%).

Partnership activity is alive and well across the health equity ecosystem as organizations establish and pursue coordinated efforts to move forward on shared health equity goals. Partnerships with provider organizations, policy and thought leaders and public health entities were reported to be most common. In addition to partnerships, organizations are seeking opportunities to influence relevant policies and laws. Respondents reported publishing academic reports and research (53%), participating in policy workgroups (52%) and supporting community organizing to impact change (49%) as their top political advocacy activities.

While all provider and public health respondents report their organizations are actively working to address multifaceted barriers to care, nearly 10% of life science companies are not engaged in these efforts. Targeted efforts to minimize access to care barriers focus on availability of providers (40%), insurance coverage (40%) and culturally appropriate programming and staffing (36%) across all organization types. A regional pattern emerged in analysis of insurance coverage barriers, with organizations in the South and Midwest more frequently prioritizing coverage gaps in their access to care efforts compared with those in the Northeast and West.

Language barriers were reported to be the least commonly addressed (21%); however, 98% of provider organizations have a language service department and 84% use medical interpreters to assure linguistically appropriate care delivery to patients with limited English proficiency.

Chart 9. “In what domains does your organization work to minimize barriers impacting access to care? Please select all that apply.”

Survey responses for all organizations and indication of which organization types are most commonly addressing each barrier. Note: Percentages will not sum to 100% as multiple responses were allowed.

Figure 9
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    A bar chart shows survey responses to the question “In what domains does your organization work to minimize barriers impacting access to care? Please select all that apply,” as well as an indication of which organization types are most commonly addressing each barrier. Note: percentages will not sum to 100% as multiple responses were allowed. Across all surveyed organizations, addressed barriers include availability of providers (40%), insurance coverage (40%), culturally appropriate programming and staffing (36%), financial barriers (33%), reducing health stigmas/education (32%), digital barriers (32%), proximity to providers (32%), transportation (27%) and language (21%).

Conclusion

The results of the inaugural EY Center for Health Equity Annual Survey point to both consistency within and variability across sectors engaged in advancing health equity goals. Findings speak to the emerging nature of most organizations’ health equity efforts and provide visibility into the evolution from strategic planning and infrastructure development to strategy execution and impact measurement. As organizations now invest to deepen their capabilities in health equity strategy, data and analytics, education, DEI, research and community engagement, it is clear there is significant work to be done to align efforts and amplify impact. With new regulations from the Centers for Medicaid and Medicare Services (CMS), National Committee for Quality Assurance (NCQA) and the Joint Commission creating renewed urgency around health equity activation in 2023, the cost of doing nothing continues to rise. In fact, health payers and providers will soon face financial risks for not addressing health inequities among the patients and populations they serve. As stakeholders continue to build out their health equity-oriented initiatives, ongoing focus on key issues such as community engagement and trust building, as well as directly confronting systemic biases fueling inequities, remain a priority.

Summary

With heightened energy and imminent new regulations around health equity across the health value chain, stakeholders are obligated to confront organizational challenges to evolve, deepen and invest in their commitment to advancing health equity.

Gail Babes, Salman Shah, Rowsha LaBranche, Sonya Wallace, Lisa Goodin, and Millka Baetcke of Ernst & Young LLP contributed to this article.

About this article

Authors
Susan Garfield, DrPH

EY Americas Chief Public Health Officer and Global Client Service Partner

Health and life sciences strategist. Helps companies transform businesses and leverage technologies. Public health leader. Addresses health equity issues and builds better public health resilience.

Yele Aluko MD, MBA

EY Americas Chief Medical Officer

Proven MD/MBA physician executive and corporate leader with astute clinical and business healthcare industry expertise and insight.

Belinda Minta

EY US Public Health Services Transformation Leader

MPH and MBA; collaborating with clients to transform and help optimize public health services; a public health professional; focuses on working with clients to Prevent. Promote. Protect.

Christine Hildreth

Manager, Health Sciences and Wellness, Ernst & Young LLP

Ardent health sector professional. Passionate about enabling innovative, equitable approaches across health and life sciences. Avid cook. Road trip enthusiast.

Perri Kasen

Senior Manager, Consulting, Ernst & Young LLP

Health equity strategist; diversity, equity and inclusion advocate; and social impact consultant with over a decade of experience. Works to realize vision of equitable experience and outcomes for all.