As health providers and patients use more technology, new ways of addressing health care disparities are emerging. In 2009 Congress passed important federal legislation that addresses the digital infrastructure for medical care, the Health Information Technology for Economic and Clinical Health Act (HITECH). Recently in 2010, Congress passed the Patient Protection and Affordable Care Act (PPACA), which reduced barriers to health information technology (HIT). In line with the technological spirit of both laws, this blog post focuses on online social networking as a digital health care solution for elderly Hispanics who face disparities in the care that they receive.
Hispanics in the United States are twice as likely as non-Hispanics to lack a regular primary care physician (PCP). Those Hispanics that do not have a PCP suffer because they tend to experience disparities in health care when compared to other patient populations. Real-time health care-focused social networking sites (SNSs) or applications within an established SNS can provide beneficial health care solutions for vulnerable patient populations such as elderly Hispanics. One-way in which a SNS can benefit elderly Hispanics and reduce their health care disparities is by supporting the Patient-Centered Medical Home (PCMH) with digital applications. In fact, if real-time social networking transpired among 1) patients, 2) patients and their health care providers, and 3) between health care providers, elderly Hispanics could potentially receive better care.
As the role of HIT increases, it has led to a growing interest in understanding the potential role of HIT in “addressing healthcare disparities among racial and ethnic minority populations.” In order to properly evaluate the potential of HIT to address health care disparities, “adoption and utilization barriers must be understood.” Because this blog post is concerned with social networking sites, the discussion here will focus on social media and its emergence as “a potent resource among healthcare consumers.” Some studies have shown that “social media utilization patterns by race suggest potential opportunities to help address healthcare disparities via” increased communication between patients and physicians.
Social media has begun to infiltrate the health care system in several ways. First, entrepreneurs who understand “health care trends and consumer demands are leading creative business startups that are developing health-oriented social networks, health content aggregators, medical and wellness applications, and tools to enable health-related vertical searches (searches focused on a specific content area).” There are a growing number of condition-specific communities such as patientslikeme, QuitNet, and CureTogether.
Although there are many benefits to HIT, there are also barriers that prevent physicians from adopting HIT. One major benefit stemming from HIT is that it can lead to positive communication in “which providers share thoughts, opinions, and information by speech, in writing, or through peer professional or social networks [which have] been shown to be associated with provider health IT adoption.” One major issue is the inability of electronic health records (EHRs) and HIT systems to communicate with each other, the impact of HIT on clinical workflows, and the absence of technical assistance for office staff and physicians. Additional barriers from the patient perspective will exist if a patient does not perceive a benefit to be gained from using technology; in fact, without a perceived benefit they are highly unlikely to use it. There is also the perception that patients might be too busy to incorporate HIT into their busy everyday lives. Also there may be “poor computer knowledge, literacy, and skills ” prevalent among target populations which could benefit from HIT. Additionally, “lack of cultural relevance as well as privacy and trust concerns all have been reported as barriers to the use of [consumer health informatics] tools and applications.” In framing technological health care solutions for a minority population such as Hispanics, it is important to consider cultural issues in any implementation because cultural issues could deter use by a given patient population.
There are several proposed ways in which HIT can reduce health care disparities. For example, if clear and accurate patient information were to be presented to a physician in an electronic setting it could lead to the promotion of high-quality personalized care and reducing select health care disparities. Additionally, EHRs could provide the physicians that serve elderly Hispanics more accurate information and help them make better treatment decisions. The largest benefit would be the ability to connect “physicians with other [physicians or patients]…[and also] tools such as e-mail, e-consultation, e-prescribing, [which could] enable providers to connect with other healthcare professionals” in a more fluid manner.
It is important that the above mentioned benefits are implemented in communities where there are underserved Hispanics or other vulnerable patient populations. It is urgent that those with the highest health care disparities benefit from such technologies because historically their needs have not been met. Scholars have already noted that “telemedicine, remote monitors and sensors, patient e-mail, and increasingly the Internet and social media, connect providers and healthcare systems to patients and caregivers.” The idea is that greater communication can reduce health care disparities. When dealing with a historically vulnerable patient population such as elderly Hispanics who face various types of social issues, I believe that easier access to their health providers can make a big difference in improving their health care outcomes.
An HIT tool that connects providers with patients could reduce health care disparities by “enabling increased monitoring of important clinical parameters” in a way that is not currently taken advantage of for minority patients. Increased communication will allow physicians to stay in contact and monitor their sickliest patients through enhanced doctor-patient communication. As technology and health care merge, it is vital that vulnerable patient populations, such as elderly Hispanics, are identified so that they can be included in the technological healthcare solutions being proposed.
Felipe De Los Santos is in his last year at Seton Hall University, School of Law. Felipe is set to graduate from Seton Hall in May 2013 with a Health Law Concentration. He graduated from Connecticut College in 2007 with a B.A. in English and Economics. From 2007-2009, he worked in finance as a Consultant for ALaS consulting between New York and Delaware. During his first year of law school Felipe interned with the New York State Majority Leader (2009-10).
Presently Felipe works as a Project Manager for a New York State health care company in the Community Based Programs division. Felipe manages and develops projects that focus on chronically ill elderly patients in New York City. As part of his responsibilities Felipe develops marketing strategies and action plans to support targeted patient populations who can benefit from managed long-term care. Currently, Felipe is involved in launching a Medicare/Medicaid Advantage Plan. Felipe’s work with vulnerable patient populations and interests in technology, have made the crossroad of technology and healthcare an interest that he has written about in law school. Felipe’s health reform interests include improving health care access and outcomes for vulnerable patient populations.
Felipe may be reached at email@example.com
I highly recommend Kimani Paul-Emile’s provocative article in the latest issue of the UCLA Law Review, Patients’ Racial Preferences and the Medical Culture of Accommodation, in which she “makes the counterintuitive claim … that the law does and should permit” physicians and hospitals to accommodate “patients’ racial preferences with respect to their choice of physician … in the hospital setting.” Such accommodation is, Professor Paul-Emile reports, a quiet, but routine, occurrence, one that recent studies suggest “may not only alleviate race-based health disparities but also constitute a life-saving measure for many racial-minority patients.”
Professor Paul-Emile’s article begins with a concise and helpful summary of the relevant default legal rules, in particular the right of patients to refuse medical treatment and the obligation of hospitals to provide care in an emergency. As Professor Paul-Emile explains, “[i]f a patient who desires treatment will not yield in his preference for a provider of a particular race and will not agree to a transfer, then the hospital is faced with the dilemma of choosing between (1) having a physician unwanted by the patient forcibly perform the [Emergency Medical Treatment and Active Labor Act]-mandated medical screening, thereby violating informed consent and battery laws, and (2) rejecting the patient in violation of EMTALA, thereby risking liability and the chance that this decision will cause the patient to suffer, experience grievous harm, or die.”
The article goes on to analyze hospitals’ decisions to accommodate a patient’s race-based request for a new doctor under Titles II, VI, and VII of the 1964 Civil Rights Act, and concludes that although “it is difficult to imagine preferences of this sort indulged in any other sector,” in the hospital setting such accommodation does not violate anti-discrimination laws. Professor Paul-Emile goes further, arguing that accommodation “may be one of the best available means of enforcing Title VI’s mandate to enable individuals to enjoy the benefits of a covered entity or program, regardless of race, color, or national origin” to the extent that it “counter[s] the effects of implicit bias, discrimination, and stereotyping by physicians[.]”
Professor Paul-Emile concedes that “the notion of white patients rejecting minority physicians for bigoted reasons in emergency departments and other hospital settings is deeply troubling and uncomfortably reminiscent of the type of discrimination that the civil rights statutes were designed to eliminate[,]” but she counters with empirical evidence (1) that “requests for treatment by a physician of a particular race are more often accommodated when made by racial minority patients” and (2) that the benefits of racial concordance are many, including longer visits characterized by patient-centered participatory decision-making.
Reading Professor Paul-Emile’s article, it struck me that for every patient who insists on a change of doctor, there are likely many more who assume, rightly or wrongly, that they have no choice and so endure discriminatory treatment in the hospital setting. Accommodating the demands of the few who speak up is at best a partial solution. Professor Paul-Emile does not deny this. She concludes her article with a call for an increase in the diversity of doctors and for an expansion of “cultural awareness at all levels of practice and training to enable providers to interact more effectively with various patient populations”—worthy, if daunting, goals.
Recommended Reading: “Breaking the Cycle of ‘Unequal Treatment’ with Health Care Reform: Acknowledging and Addressing the Continuation of Racial Bias”
Ruqaiijah A. Yearby, Professor of Law and Associate Director of the Law-Medicine Center at Case Western Reserve University School of Law, has written another important article focusing attention on persistent racial disparities in health care access and outcomes, “Breaking the Cycle of ‘Unequal Treatment’ with Health Care Reform: Acknowledging and Addressing the Continuation of Racial Bias.” An abstract of the article is available on SSRN, and the full article is forthcoming in the next volume of the Connecticut Law Review. Here’s a preview to whet your appetite.
The article begins by reviewing evidence of racial disparities in health care status and access to quality health care in the United States, such as the 1985 Heckler Report, 2002 Institute of Medicine Unequal Treatment Study, and 2007 National Healthcare Disparities Report. It then identifies racial bias as the root cause of racial disparities and summarizes empirical studies demonstrating that racial bias creates a barrier to access to health care and causes poor health outcomes for African-Americans. Professor Yearby describes three types of racial bias in health care, interpersonal, institutional, and structural:
Interpersonal bias is the conscious (explicit) and/or unconscious (implicit) use of prejudice in interactions between individuals. Interpersonal bias is best illustrated by physicians’ treatment decisions based on racial prejudice, which results in the unequal treatment of African-Americans. . . . Institutional bias operates through organizational structures within institutions, which “establish separate and independent barriers” to health care services. According to Brietta Clark, institutional bias is best demonstrated by hospital closures in African-American communities. Finally, operating at a societal level, structural bias exists in the organizational structure of society, which “privile[ges] some groups . . . [while] denying others access to the resources of society,” including health care. An example of structural bias is the provision of health care based primarily on ability to pay, rather than on the needs of the patient.
A particularly eye-opening section of the article describes the growing dominance of aversive interpersonal racial bias in which a physician “believes that everyone is equal but harbors contradicting, often unconscious, prejudice that minorities (such as African-Americans) are inferior.” Studies show that when doctors rely on “conscious and unconscious prejudicial beliefs” instead of “on individual factors and scientific facts,” it can affect treatment decisions, leading to racial disparities in medical treatment and “inequities in mortality rates between African-Americans and Caucasians.” In addition, patient perception of aversive racism by their medical provider increases stress levels, which also has a negative effect on health status.
Despite passage of Title VI of the Civil Rights Act, which “prohibits health care entities [but not physicians] receiving government funding from using racial bias to determine who receives quality health care,” and various government initiatives to eradicate racial disparities in health care, the article reports evidence showing that “unequal treatment of African-Americans because of their race is the main cause of the continuation of racial disparities in health care.”
Professor Yearby acknowledges that the Affordable Care Act (“ACA”) is an important first step to addressing these disparities. Importantly, several provisions, such as the mandate, Medicaid expansion, premium subsidies, and essential health benefits, should expand access to meaningful health insurance for many previously uninsured minorities. The Act further attacks structural bias “by limiting a charitable hospital’s ability to charge uninsured patients more than the amount generally billed to insured patients for emergency and other medically necessary care.” The ACA also standardizes racial data collection, makes the Office of Minority Health a part of the Office of the Secretary of Health and Human Services, creates offices of minority health in various other federal agencies to study health disparities, and applies civil rights laws, including Title VI, to its provisions.
Despite these strengths, Professor Yearby criticizes the ACA for not fully addressing structural racial biases and ignoring institutional and interpersonal racial biases, which will permit racial disparities to persist and possibly worsen:
If health care professionals continue to harbor implicit and explicit interpersonal bias against minority patients, which prevents them from providing quality health care to these patients, simply increasing minority patient access to health insurance and, thus access to health care services, is not going to improve overall care for minority patients. Moreover, increasing access to insurance and preventative services means very little when patients do not have a health care facility located in their neighborhood — a result of institutional bias.
The article also criticizes the government’s continued failure to remedy significant flaws in its civil rights enforcement system in the health context.
After highlighting the ACA’s flaws, the article then makes a variety of recommendations, including:
- Educating physicians about the three levels of racial bias and how each impacts medical treatment and patients
- Having federal and state regulators review institutional plans to close or relocate quality health care facilities for disproportionate harm on African-American communities and, where appropriate, requiring the institution to take remedial steps to ameliorate any disparate impact
- Adding physicians to the definition of health care entities or defining payments to them as federal financial assistance under Title VI so that civil rights actions may be brought against health care professionals
- Linking regulations governing racial disparities with civil rights enforcement by, for example, requiring that racial disparities data collected under the ACA be provided to the Office for Civil Rights and integrating civil rights enforcement into regulations governing health care facilities
Regardless how the Supreme Court rules on the ACA in the coming weeks, Professor Yearby’s article provides a valuable blueprint for continued and needed reform to “begin to break the cycle of unequal treatment.”
As proof that the only news in health law does not involve the Supreme Court’s consideration of the challenge to the Affordable Care Act, here are some interesting recent articles that are worth a read:
1. Frank McClellan and others recently released the results of their study, “Do Poor People Sue Doctors More Frequently? Confronting Unconscious Bias and the Role of Cultural Competency.” Some doctors perceive that socioeconomically disadvantaged patients tend to sue their doctors more frequently, which has influenced them not to provide care or to provide care in different ways to this population. For example, 57 percent of physicians polled in California in 1995 cited this belief as important in their decision not to treat Medicaid patients. Yet McClellan and his co-authors review studies showing that, to the contrary, poor patients tend to sue their physicians less often than other groups. Indeed, there is evidence that patients in lower socioeconomic groups are also less likely to file nonmeritorious malpractice claims. One possible explanation that the authors of this project offer to explain this disconnect between physician perception and fact is unconscious or implicit bias, which “describes thinking and decision making affected by stereotypes without one being aware of it” that “can explain why people may consciously believe in a truth, whereas their behavior, affected by subconscious prejudices, is contrary to that truth.” For example, physicians unconsciously concerned that poor patients will not adequately compensate them for their care “might consciously or unconsciously presume poor patients are more likely to sue as an excuse or way of avoiding the presumed difficulty associated with collections from such patients.” The authors of this study make recommendations to confront unconscious bias and provide culturally competent care (“CCC”), including increasing diversity, educating providers about CCC, improving provider communication skills, and enhancing patient health literacy. CCC educational efforts are especially valuable in specialties like orthopaedic surgery, where approximately 84 to 89 percent of providers are white males. It is thought that these efforts will improve medical care to lower socioeconomic groups and reduce the risk of malpractice claims.
2. In “Diversion of Offenders with Mental Health Disorders: Mental Health Courts,” Sarah Ryan and Dr. Darius Whelan review the use of mental health courts in the United States, Canada, England, and Wales and consider whether these courts should be established in Ireland. The article first reviews Therapeutic Jurisprudence (“TJ”), a foundational theory underlying problem-solving courts like mental health and drug courts that “promotes the employment of a ‘problem-solving pro-active and results oriented posture that is responsive to the current emotional and social problems of legal consumers.'” While advocating its strengths, the authors also warn of the danger that paternalistic applications of TJ can water down due process and rule of law values. They then identify and compare features of mental health courts that have developed in the United States, Canada, England, and Wales since the pioneer court started operating in Broward County, Florida in 1987. After evaluating the main merits (e.g., more appropriate treatment and potentially reduced recidivism and costs) and criticisms (e.g., concerns about coercion, waiver of due process rights, stigmatization and segregation of the mentally ill, diversion of resources, and lack of empirical data that they are effective) of these courts, the authors conclude that mental health courts could offer a partial solution to the challenges facing Ireland’s criminal justice system. Not surprisingly, they urge policymakers to select the best features of the programs that have evolved to date and to apply TJ “in a careful manner, to avoid interference with defendants['] constitutional rights.” For example, the authors recommend that a solicitor be appointed at the first indication an offender could be eligible to participate. Further, they believe that Ireland should not require offenders to plead guilty as a pre-condition to participate in the program because such a requirement is “antithetical to the goal of decriminalising the mentally ill.” They warn, however, that for the program to be viable, Ireland would have to allocate substantial funding to develop community mental health treatment facilities.
3. Recent Harvard Law School graduate Maggie Francis has written, “Forty Years of ‘Testing, Testing': The Past and Future Role of Policy Experimentation in Healthcare Reform,” which reviews the federal government’s use of pilot projects and demonstration projects over the past forty years to test innovative health reform ideas. As Ms. Francis describes, her article is the “first . . . in the legal literature to analyze the use of systemic policy experimentation by the federal government to reform the healthcare system.” She describes the number and types of problems facing the healthcare system and why policymakers have chosen pilots as a means of addressing these problems. The article then evaluates whether pilot projects are a useful tool in healthcare reform. Ms. Francis identifies numerous advantages to pilots, including that they provide some cover to controversial innovations from political pressures and permit government to try multiple theories in different pilots to assess what works better in different populations, locations, etc. and to make adjustments based on experience that should make large-scale implementation smoother. She also warns of some possible roadblocks, including lack of adequate information and competence to select the right pilots and then to oversee their implementation and evaluation. A common criticism of these programs is that they take too long to test new ideas and expand those that are successful. Securing consistent funding has also been a challenge. In addition, political interference and gamesmanship can undermine efforts to innovate. Ms. Francis concludes that, despite their limitations, pilot projects satisfy policy makers’ need for information about reform ideas and their consequences and offer the most promise where “organizational challenges, rather than stakeholder opposition and distributional problems, are the primary obstacle to reform.” As a result, she posits that pilots might be more successful at encouraging widespread adoption of less controversial innovations, such as medical homes, than with contributing “significantly to the goal of cost control, which necessarily raises contentious distributional issues among powerful stakeholders in the healthcare industry and is likely to trigger rent-seeking behavior by interest groups.” Ms. Francis’s observations are not merely historically interesting but rather offer important insights given the variety of pilot projects included in the ACA to help identify a politically viable way to bend the healthcare cost curve while improving quality. Ms. Francis reviews the diverse medley of pilots in the ACA, including, but far from limited to, the creation of the Center for Medicare and Medicaid Innovation, reminding us all how much more there is to the ACA than just the mandate and how much we will learn from its implementation.
HHS Seeks to End Healthcare Disparities, Announces Pipeline Program for Public Health and Biomedical Science
Case Western’s Disparities blog has a brief article/announcement well worth considering. They write:
The Department of Health and Human Services has devised a plan to end racial and ethnic disparities throughout the United States. The new plan will focus on recruiting undergraduates from underserved communities and steer them towards a careers in public health and biomedical science.
The Case Western blog links to an article from Medpage Today which adds that in addition to the pipeline program, HHS has come forward with a plan
for allocating more resources to community health centers, a call to train more people in medical interpretation to help serve patients with a limited command of English, and a push for reimbursement for interpretation services.
Medpage Today also notes that
The strategy tackles a long-acknowledged and persistent problem in the U.S. healthcare system: racial and ethnic minorities are more likely than whites to experience poorer quality care; more likely to suffer from serious illnesses, such as diabetes or heart disease; and less likely to get preventive care.
The report calls attention to racial and ethnic disparities in the healthcare workforce. According to a 2008 report from the Association of American Medical Colleges, although Hispanics account for about 16% of the total U.S. population, they make up less than 6% of all physicians. African-Americans account for a similar percentage of the U.S. population, but only a little more than 6% of all doctors are black.
I think Case Western gets it right when they say that
This approach is to attempt to diminish these disparities by creating grounds for all to become a part of the ever growing field of public health and biomedical sciences and be able to relate to the populations in which the racial and ethnic occur and provide better care while doing so.
Without diminishing the need for technical ability, to be able to understand and relate to a patient is no small thing. To be able to effectively communicate is key in a medical setting.
Last summer I wrote the following:
A recent study highlighted in the Wall St. Journal’s Health Blog points to both a discrepancy in perception between hospital doctors and their patients and a failure to communicate.
The study was conducted by Douglas P. Olson, MD and Donna M. Windish, MD, MPH. The authors noted as “Background” in the study abstract that:
Hospital surveys indicate lack of patient awareness of diagnoses and treatments, yet physicians report they effectively communicate with patients. Gaps in understanding and communication could result in decreased quality of care. We sought to assess patient knowledge and perspectives of inpatient care and determine differences from physician assessments.
The results of the study were derived from two validated questionnaires given to inpatients treated by “house doctors” over a course of roughly eight months at one hospital.The corresponding doctors were also queried. Eighty-nine patients and 43 doctors participated.
The survey – which the authors note is limited by its reach (one institution), patient characteristics (older, indigent and less-educated than average), and general responses, rather than one-to-one-patient-physician comparisons – is published in the Archives of Internal Medicine.
The results? From the abstract:
- Only 18% of patients knew their main doctor by name.
- Sixty-seven per cent of doctors believed their patients knew them by name.
- Fifty-seven per cent of patients knew their diagnosis.
- Seventy-seven per cent of doctors believed their patients knew their diagnosis.
- Fifty-eight per cent of patients thought that physicians always explained things in a comprehensible way.
- Twenty-one per cent of doctors stated they always provided explanations of some kind.
- Sixty-six per cent of patients reported receiving a new medication in the hospital, 90% noted never being told of any adverse effects of these medications.
- Ninety-eight per cent of doctors stated that they at least sometimes discussed their patients’ fears and anxieties.
- Fifty-four per cent of patients said their doctors never did this.
Interestingly enough,the WSJ article notes that the
responses didn’t significantly differ by sex, age, race, language or payment source, for the patients, or level and type of training, for the doctors.
Only 57% of patients knew their diagnosis? Which is to say that 43% did not? 90% not told of potential adverse reactions to new medication?
The study did not take into account the race or linguistic ability of the doctors– just level and type of training. Given the paucity of African American and Hispanic doctors, one wonders if one could have produced a significant number for doctor race and language. But we do know this– as stated above, the healthcare outcomes for racial and ethnic minorities is significantly worse than that of Whites. Is it far-fetched to think that cultural knowledge and linguistic ability– in a practice that requires communication– could lead to better outcomes? I have no belief that the HHS plan is the be all, cure all. But I think it’s a good step in the right direction.
Medpage Today offers the following quote: “Health disparities have burdened our country for too long,” said Assistant Secretary for Health Howard Koh, MD, MPH. “This plan reaffirms and revitalizes a national commitment to helping all persons reach their full health potential.”