Realizing the Promise of Health Information Technology to Reduce Health Disparities

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 felipe.delossantos@gmail.com

 

Recommended Reading: ‘Patients’ Racial Preferences and the Medical Culture of Accommodation’

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.”

Recommended Reading

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.

Happy reading!

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.

And that

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.

According to WSJ:

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.”

Godspeed.

Review of Reconsidering Law and Policy Debates: A Public Health Perspective

Reconsidering Law and Policy Debates: A Public Health Perspective, edited by John Culhane, is a superb collection of thought-provoking essays which features some of the most well-regarded health law scholars in the US. It also includes contributors from schools of public health, public affairs, and public administration. The chapters are uniformly well-written and instructive. Though I cannot in this brief review give consideration to all of the essays, I will try to highlight contributions related to some of my own areas of interest in the intersection between public health and medico-legal research.

Several authors focus on the difficult questions raised by extreme inequality. For example, Vernellia R. Randall’s Dying While Black in America reflects on the disturbing disparity between white and black death rates in the US. A black American male can expect to live seven years less than a white American male, and black women face a four-year gap. Randall explores a number of potential explanations, including discriminatory policies and practices, lack of language and culturally competent care, inadequate inclusion in healthcare research, and hidden discrimination in rationing mechanisms. Randall argues that these disparities will never be addressed effectively until the legal system develops doctrines that can deter not only intentional discrimination, but also “negligent discrimination in healthcare:”

Negligent discrimination in healthcare would occur when healthcare providers failed to take reasonable steps to avoid discrimination based on race when they knew or should have known that their actions would result in discrimination. An example of this would be decisions to close inner-city hospitals and move them to the suburbs. (86)

Randall expertly characterizes race as a key “social determinant of health” in the United States. Countering the many current legal doctrines that promote the legitimation of discrimination, Randall envisions the type of guarantees of equality that will be necessary to realize the antisubordination and antisubjugation principles that animate the 14th Amendment properly understood.

Diane E. Hoffman also addresses stunning inequalities, this time on a global level. Hoffman’s long engagement with end-of-life care informs a consistently sensitive and insightful public health perspective. Considering the situation in the United States, Hoffman concludes that “it is not as all clear that we would want to give the state a public health justification for taking on end-of-life care,” because “we might have trouble reining in the government and preventing it from implementing increasingly more coercive measures” (59). This judgment is particularly pertinent in a political environment where extreme inequality and ever-lower taxes on the wealthiest have imperiled many important health programs for the aged.

However, Hoffman comes to a different conclusion in the case of many developing countries, where the question is less one of rationing access to life extending technologies than it is one of extending access to basic treatments for pain. In a sobering series of statistics, Hoffman presents a tragic panorama of human suffering. In India, only 1% of the 1.6 million people enduring cancer pain each year are likely to receive any type of pain medication. Morphine dispensaries are rare; Calcutta, with 14 million residents, has only one. Though nearly half its population is extremely poor, India is not an outlier. While developing countries account for 80% of world population, they use only 6% of the morphine consumed each year. Sometimes, shortages of medical personnel help explain the problem: for example, in Sierra Leone, there is only one doctor for every 54,000 people (as opposed to a 1:350 ratio in the US). But Hoffman gives several examples of easily preventable policies and business practices that keep painkillers out of the hands of the world’s poorest individuals. This is a truly neglected global crisis, generating levels of suffering that are rarely encountered or even imagined in the developed world.

Returning to the US, the last two chapters in the book are very interesting contributions to ongoing debates about the nature and role of tort doctrine. Elizabeth Weeks Leonard expertly deconstructs the usual dichotomy between tort law’s individualism and the population focus of public health. As she notes, cases involving asbestos, lead paint, silicone breast implants, the Dalkon shield, hazardous autos, tobacco, firearms, Phen-Fen, OxyContin, and Vioxx have all combined efforts by individuals to secure compensation for injuries with broader strikes against destructive products and practices. Weeks succeeds in demonstrating the “counterintuitive fit between tort law and public health law” (189), arguing that each “offers approaches to addressing inevitable conflicts in organized society between individual interests and community needs.”

Jean Macchiaroli Eggen tries to make the fit better by focusing on punitive damages. Toward the end of her chapter, she proposes that states solve the “plaintiff windfall problem” in punitive damages by requiring that “the portion of the punitive award the plaintiff does not receive [due to split-recovery statutes and other measures] be allocated to a state or private program that will enhance the deterrence of the conduct that gave rise to the warden the particular case.” The contributions of both Weeks Leonard and Macchiaroli Eggen would be of great interest to tort classes and seminars considering the difficult issues raised by judicial efforts to address public health concerns.

John Culhane is to be commended for bringing together such an illustrious group of contributors to address public health, an issue that has been neglected in law schools. Knowing full well that factors like income, race, pollution, and even commute length may have a far greater impact on health than, say, dispute resolution methods used by insurance companies, law professors nevertheless tend to focus on purely legal topics. (I am as guilty of this as anyone, and credit this book (and many interventions by Daniel Goldberg) for pushing me to do more to consider the social determinants of health in my own work.) Well after the sturm und drang surrounding the constitutionality of the ACA has dissolved, we will still face problems of balancing liberty, equality, and welfare that this book’s thoughtful contributors address. Their voices deserve to be heard in those future, more substantive, debates.

ACOs and Racial and Ethnic Disparities: A Role for Community Stakeholders? Part Two

Part I of this post reviewed concerns raised by Craig Evan Pollack, MD, MHS, and Katrina Armstrong, MD, MSCA in their recent commentary in JAMA that implementing accountable care organizations (ACOs) will exacerbate racial and ethnic disparities in health care.  After considering the authors’ suggestions for steps CMS can take before finalizing its proposed rule to avoid this unintended consequence, I wondered whether community stakeholders might also be able to help stave off this negative policy outcome.  Now we pick up where I left off … what are community stakeholders and what role might they play in ACO formation and implementation?

CMS’s proposed rule has vague language requiring that the ACO  “establish partnerships with community stakeholders in order to advance the three-part aim of better care for individuals, better health for populations, and lower growth in expenditures” (proposed Section 425.5(d)(3)(v)).  The ACO also must describe in its application how it will partner with community stakeholders (proposed Section 425.5(d)(3)(iv)(B)(9)(ix)(H)). The lengthy preamble to the proposed rule further states that an ACO will be deemed to have satisfied this application requirement by including a community stakeholder organization on its governing body.  See 76 Fed. Reg. 19,527, 19,541 (Apr. 7, 2011).

The proposed rule, despite its length, does not shed much light on what the community stakeholder is.  Who or what is the community stakeholder?  Who does the community stakeholder represent?  Does it have an obligation to represent only the beneficiaries in the ACO or all in the relevant community?  Regardless of the answer, how can it know who its member beneficiaries are or what the relevant community is, since assignment is done retrospectively?  How is the community stakeholder selected — by the ACO?  Its beneficiaries?  What does CMS mean by partnership? If a community stakeholder is on the ACO’s governing body, is it a voting member?  There are myriad questions left unanswered by the proposed rule.

The preamble to the proposed rule, however, reveals a glimpse of CMS’ thinking when it discusses integrating community resources within the context of developing individualized care plans for targeted high-risk and multiple chronic condition patient populations as part of adherence to a “patient-centeredness criterion”:

The individualized care plans should include identification of community and other resources to support the beneficiary in following the plan. To this end, we believe that a process for integrating community resources into the ACO is an important part of patient centeredness. A wide variety of organizations, although not necessarily ACO participants may be considered a community resource, including: Employers, commercial health plans, local businesses, state/local government agencies, local quality improvement organizations or collaboratives (such as health information exchanges).  Collaboration with these types of community resources can be an important part of enabling ACOs to take account of the entirety of Medicare beneficiary population’s needs relative to their environment. Community stakeholder engagement in an ACO could be explicitly incorporated via community representation on the governing body, by having a community representative on an advisory board, or by other innovative mechanisms.

[76 Fed. Reg. 19,527, 19,550 (Apr. 7, 2011).]

CMS specifically invited ACOs in their applications to “describe additional target populations that would benefit from individualized care plans.”  76 Fed. Reg. 19,527, 19,551 (Apr. 7, 2011).]

Community stakeholders should be responsible for coordinating this collaboration with community resources and partners and helping beneficiaries most at-risk by directing ACO resources to the toughest cases.  Given the racial and ethnic segregation concerns discussed in Part One of this post, CMS should make clear that racial and ethnic minorities are among the targeted high-risk patient populations to which community stakeholders — and the ACO — must attend to satisfy the “patient-centeredness criterion.”  Part of helping ACOs “take account of the entirety of Medicare beneficiary population’s needs relative to their environment,” 76 Fed. Reg. 19,527, 19,550 (Apr. 7, 2011), must involve community stakeholders who are keenly aware of underserved or segregated groups in the ACO’s geographical area and help the ACO use community resources to outreach to these groups.

This outreach can start with education.  Patients of any race or ethnicity may gain access to higher quality care by choosing to see a doctor in an ACO that is reporting stronger quality measures — if they are aware of their rights and supported in making a change.  Community stakeholders can educate these groups about the quality data available to help them evaluate the care available to them and their right to seek care from any Medicare provider.  Helping patients, regardless of their race or ethnicity, embrace their power to cherry pick providers based on quality could mitigate the risks of further segregation that concerned the authors of the JAMA article (at least in regions where beneficiaries have a choice of providers).  Community stakeholders can help find the Rosa Parks of health care segregation to stand up and say, “I will not ride in the lower quality back of the health care bus anymore!”

But we could miss this bus if the final rule remains as skeletal as the proposed rule.  I am confident that CMS has a clear vision of productive partnerships with community stakeholders that advance its goals for better care for individuals and better health for populations.  I hope it paints a fuller picture in its final rule.

ACOs and Racial and Ethnic Disparities: A Role for Community Stakeholders? Part One

A recent commentary in the Journal of the American Medical Association warns that accountable care organization (ACO) formation may unintentionally exacerbate racial and ethnic disparities in health care.  As has been discussed in several posts on this blog (such as here, here, here, and here), CMS’s proposed rule to implement section 3022 of the Affordable Care Act details the requirements for forming ACOs to participate in the Medicare Shared Savings Program.  With the period to comment on this proposed rule closing June 6, 2011, the time is ripe to bring these concerns to CMS’ attention, along with proposals for revisions to CMS’s proposed rule, so that the final rule takes every step possible to minimize these risks.

In “Accountable Care Organizations and Health Care Disparities,” published in JAMA on April 27, 2011, Craig Evan Pollack, MD, MHS, and Katrina Armstrong, MD, MSCA, reference the well-documented racial and ethnic disparities in health care in this country, which they describe as de facto segregation.  For example, they cite various studies showing that “[b]lack and white patients tend to receive care from different clinicians who work at different hospitals and different health care systems,” and, moreover, that many (though of course not all) “hospitals that treat a large proportion of black patients appear to provide lower-quality care than hospitals that treat a larger portion of white patients.”

The authors worry that the process of forming ACOs may further concentrate patients by race and ethnicity in particular health care organizations.  As they explain:

Although not explicitly selecting patients by race, ethnicity, or socioeconomic status, the current reality is that profitability in health care is strongly correlated with caring for fewer low-income patients and low-income patients are disproportionately not white.  To the degree that the creation of an ACO enables wealthy practices to preferentially align with one another, this process has the potential to further concentrate wealth and racial/ethnic groups within certain ACOs.

In addition, they note that, once established, the ACO-model creates a strong incentive for an ACO to do all it can to keep its assigned beneficiaries coming back for care and from seeking care outside of the ACO, where the ACO cannot control the costs.  If the ACO successfully retains its patients, and prevents movement between and among ACOs, the authors fear this incentive is “likely to accentuate racial/ethnic differences in where patients receive care.”

The authors also highlight the risk that health systems that disproportionately treat lower-income patients often will be not only separate but also unequal because they often have fewer resources to invest in improvements to value.  Absent these investments, it will be harder for these ACOs to qualify for shared savings.  And around the gerbil wheel we go, as racial and ethnic disparities widen.

In addition, the authors are concerned that hospitals that disproportionately care for patients from certain racial and ethnic groups may elect not to bother going through the effort to form an ACO, given the high start-up costs and because these patients’ care is too fragmented and difficult to coordinate.  (But see the Medicaid ACO-model that Dr. Jeffrey Brenner is developing in Camden, New Jersey to focus resources on the 1 percent of the city’s population that accounted for 30 percent of its health costs, as discussed, here, here, and here.)

As Drs. Pollack and Armstrong summarize:

In a worst-case scenario, the cherry picking of practices in ACO formation and the process of owning patient panels will concentrate white patients within certain hospital systems that will be able to make the greatest investment in improving value and will receive the greatest benefit from the ACO arrangement.  Although not intentional, this scenario leaves lower-income patients who are less likely to be white more concentrated in hospital systems that have relatively fewer financial resources and less ability to compete in a new world of accountable care.

So what can we do to reduce the risk of these unintended consequences of ACO formation?

In fairness, CMS’s proposed rule already includes some provisions that may mitigate these risks. For example, the proposed rule makes it harder for ACOs to cherry pick patients because assignment is done retrospectively (proposed Section 425.6(b)).  Thus, in theory, because patient choice of provider drives assignment of beneficiaries to ACOs, patients of all races and ethnicities can choose the provider who offers the highest quality care.

Reality, of course, limits the power of patient choice, where, for example, there are few provider options in a given geographical region.  The proposed rule does not address the lack of provider choice in underserved regions, although it does include certain provisions that give a preference to providers who tend to serve underserved populations.  For example, the proposed rule provides a greater percentage of shared savings to, and demands a smaller percentage of shared losses from, ACOs that include a rural health clinic (RHC) or federally qualified health center (FQHC) (proposed Sections 425.7(c)(7) and 425.7(d)(6)).  It also exempts ACOs from the 2 percent net savings threshold adjustment under the one-sided risk model where: all participants are physicians or physician groups; 75 percent or more of its assigned beneficiaries reside in counties outside of a metropolitan statistical area; 50 percent or more of its assigned beneficiaries were assigned based on services received from Method II critical access hospitals; or at least 50 percent of its assigned beneficiaries had at least one encounter with a participating FQHC or RHC (proposed Section 425.7(c)(4)). The proposed rule also recognizes a rural exception (proposed Section 425.5(d)(2)) to the Proposed Statement of Antitrust Enforcement Policy regarding ACOs Participating in the Medicare Shared Savings Program.  These provisions may make it easier for ACOs to form and work for quality improvements in underserved areas.

The authors of the JAMA article recommend a number of additional steps CMS should take to minimize the risk of unintentionally further entrenching racial and ethnic disparities through ACO implementation.  For example, they suggest that CMS consider patients from medically underserved racial and ethnic groups and individuals with low-socioeconomic status as at-risk when making the required adjustments for patient characteristics (proposed section 425.7(b)) and monitoring to be sure providers are not avoiding at-risk patients (proposed Section 425.12(b).   They also suggest that it may be necessary to use incentives to make sure all populations have an opportunity to be in ACOs.   To assist in evaluating the effect of ACO formation on racial and ethnic groups, they also recommend requiring ACOs to report quality indicators by race and ethnicity; studying whether there is a relationship between the distribution of patients by race and ethnicity among ACOs and quality of care received; monitoring what patient populations are excluded from this reform because their providers elect not to seek to form ACOs; and monitoring hospital and practice consolidations to “avoid patient and practice cherry picking in ACO creation . . . from a disparities [and not just an antitrust] perspective.”

Each of these suggestions warrants serious evaluation.  While some, such as race-based incentives or classifications, may face steep political and legal opposition, it is difficult to conceive of a viable challenge to the measured recommendations seeking data to inform evaluation of ACO implementation.  Indeed, these would serve CMS’s oft-repeated goal to make changes and improvements to the Shared Savings Program as it learns what works and what doesn’t.  See 76 Fed. Reg. 19,527, 19,560 (Apr. 7, 2011).

In addition to these suggestions, I wonder if community stakeholders might also play a role in mitigating the risk of further segregation of care.  Who are community stakeholders, you might ask?  You’re not alone.  Little appears to have been written about them.  But stay tuned for Part Two of this post, which will explore this elusive player in ACO formation.

[Ed. Note: Part Two may be found here.]

Missing Care, Missing Drugs: Canaries in the Medical Coal Mine

While Washington has been focusing on repealing or rolling back parts of the Affordable Care Act, persistent embarrassments of the American health system show how untenable the status quo is. Both lower and middle class families are facing serious problems as they contend with providers’ and insurers’ cost constraints.

I’ll first address the familiar issue of health disparities. According to a recent news report, Lauren E. Wisk of the School of Medicine and Public Health at University of Wisconsin, Madison “examined data from the 2001-2006 Medical Expenditure Panel Surveys on 6,273 families with at least one child.” Wisk’s study shows that excessive financial burdens from cost-sharing are keeping many children from getting the care they need:

Families aren’t choosing to spend their money on going to the doctor when someone is sick because of how much it cost them to see the doctor last time. They’re sacrificing their health because it costs too much to be healthy. . . . We expect that if people aren’t getting the care they need, they’ll be sicker as a result. When you put this all together and look at the big picture, the cost of health care in the U.S. could actually be causing Americans to be sicker.

We might wonder: how can this be? Isn’t the economy in recovery? But we’ve seen this picture before, in the developing world. Growth does not help everyone. India, for example, has had astonishing economic growth, but it “is home to about a third of the world’s underweight and stunted children under the age of 5,” and “the impressive economic growth of the past decade has made only a modest dent into the obstinately high incidence of severe underweight and stunting of children in the country.” As Amartya Sen has shown, not only China, but also Bangladesh, are ahead of India in reducing the number of underweight children, despite the fact that “GNP per capita of $1,170″ in India, “compared with $590 in Bangladesh.” The critical number really is median GNP, and beyond that, real allocation to the sectors and concerns that matter. As the US surpasses Ivory Coast and Pakistan in inequality, don’t count on gains from growth to go to the people who need it.

It’s not just poor patients who need to worry about misplaced priorities in the health care system. We are increasingly seeing shortages of important drugs in the US. (Apparently this issue first caught mass media attention when prisons had a difficult time finding a key barbiturate used in executions.) Given that Congress is busy planning to cut funding for the statistical abstracts of the US and energy research (adding to prior DOJ cuts to studies of industrial concentration in the US), we shouldn’t be surprised to learn that “no one is systematically tracking the toll of the shortages.” Not many journalists are left to report on the government’s failure to report, either. But the head of FDA’s Drug Shortages Program is worried: “This is affecting oncology drugs, critical-care drugs, emergency medicine drugs.” It turns out that much-ballyhooed globalization has some downsides, too:

“We’ve certainly reached a very global supply chain for drug products, with the active ingredients typically made outside of the United States,” said [a] vice president for regulatory sciences at the Generic Pharmaceutical Association. “It could be Europe, India — some cases China. If there’s a problem at a facility in Italy or India, it leads to disruption of the drug supply in the United States.”

And a whole new triage system has developed to address an entirely avoidable crisis:

“We have heard some horror stories where patients are really begging to get the drugs from other sources and where practices or institutions are forced to kind of triage patients and save the drugs for those — quote — most curable, where they have the best prognosis and using substitutes where there isn’t a cure possibility,” [said the] president-elect of the American Society of Clinical Oncology.

A moving piece by Hagop M. Kantarjian describes the dilemmas facing some leukemia doctors:

Recently I sent out a plea on this national crisis to 8,000 oncologists who subscribe to a monthly e-mail newsletter published by the leukemia department at the MD Anderson Cancer Center. Within 12 hours, my in-box was jammed with replies from doctors in more than 25 states, each with his or her own horror story. . . . Take, for example, the 43-year-old Kentucky father who got a substandard dose of cytarabine because his doctor used all the doses he could find but still didn’t have enough. “I don’t know what I’ll do next,” the doctor told me.

Or the 45-year-old retired Air Force lieutenant colonel from Colorado, father of an incoming Air Force Academy cadet, whose leukemia came back after six months. His doctor looked all over the state for cytarabine with no luck and so was forced to give his patient second-line therapy. Or the 15-year-old boy from Florida who is in remission but can’t get the therapy that will cure him.

I see two takeaways from this sad situation. First, the next time someone says that generic “health care costs” are too high, consider whether they really mean we need to reallocate funds from less productive sectors to this, life-threatening crisis. Second, we need to reconsider the wisdom and necessity of far-flung, fragile supply chains for critical products. Barry Lynn has been making this point for some time. His book Cornered argues that “the drive to reduce costs has led to several competing manufacturers relying on a single overseas supplier for certain components and that this makes the whole system vulnerable to an event like an earthquake, a strike, or a war that might put the single supplier temporarily out of business.” Even for those skeptical of Lynn’s thesis in, say, the automotive or computer sector, his warnings should be salient for the food and health care industries. Too many lives have been put at risk by supply chains that are not robust enough to handle predictable challenges.

Hans Rosling, Stats Guru: Income/Health in 200 Countries Over 200 Years in 4 Amazing Minutes

Just too good to pass up: via TPM and the BBC, Hans Rosling, Professor of International Health at Karolinska Institute and Director of the Gapminder Foundation, looks at the relationship between income and health in 200 countries over a span of 200 years– in a few clear and amazingly animated minutes.

Health Care and Disparity in a “Post-Racial” Era

Seton Hall Law School recently hosted the Third National People of Color Conference, which was convened to “address critical national and global issues through the lens of legal scholarship that explicitly and implicitly examines contemporary racial context.”

The conference brought together over 400 judges, law professors, lawyers and students to our campus over the course of  four days and featured panels and speeches by people such as the Reverend Jesse Jackson; the Honorable Cory Booker, Mayor of Newark, New Jersey; Professor Derek Bell, Visiting Professor at New York University School of Law; Kathleen Martinez, Assistant Secretary of Labor for Disability Employment; The Honorable Joseph A. Greenaway, U.S. Court of Appeals, Third Circuit; Gay McDougall, United Nations Independent Expert on Minority Issues; Keith Harper, former Appellate Justice of the Mashantucket Pequot Tribal Nation; and just too many other smart and interesting people to list here. (A good account of the Conference in Diverse Magazine can be found here).

Involved in some of the on site prep work, I was unable to attend nearly as much as I would have liked. But I did have the opportunity to listen to a number of thought provoking presentations, including speeches by Jesse Jackson, Mayor Booker, Keith Harper and Katleen Martinez.

In considering the theme of the conference, “Our Country, Our World in a ‘Post-Racial’ Era,” it was made clear time and time again that despite the rhetoric that has bounced about our nation since President Obama took office, when looking at numerical indicators for well being in the United States racial identity, ethnicity, gender, sexual identity, and disability status matter.

I realize that I am saying nothing new here–nor am I saying it as well as I heard it. But I think it also bears repeating.

It is also worth noting, when looking at the disparity in health care access, utilization, and quality of received care, that here in New Jersey as a response to a budget crisis, the state recently summarily stripped over 12,000 legal immigrants of their right to health care through Medicaid. Our Center for Social Justice here at Seton Hall Law has sued the State of New Jersey for doing so as a violation of both the state and federal constitutions as a matter of, among other things, equal protection. Such actions by the state assuredly do not bode well for the health care variance numbers below; and maybe, when considering the disparities in health care, “equal protection,” in the largest sense of the word, is the appropriate lens through which to view this.

But it is also, within the context of anyone’s verbal meanderings about a supposed “post-racial” society, important to note that news of the suit was featured in the Wall Street Journal, Star Ledger, Asbury Park Press, The Record, The Daily Record, The Courier Post, Home News & Tribune, The Jersey Journal, MSNBC, PolitickerNJ, Newsday, Immigration Prof Blog and other media throughout New Jersey, New York, Pennsylvania, and Connecticut.

Reader’s comments were decidedly not kind. Having done a great deal of work with and for immigrant communities, the urban disenfranchised, Guantanamo Detainees, and others unpopular and unjustly treated, we’re used to it here at Seton Hall Law. But I invite anyone entertaining delusions about a “post-racial” era to take a look at the comments. Or, for that matter, the comments on almost any newspaper article that deals with immigration– or race.

Having said that, I also invite you to take a look at the following numbers and study results from HHS’ Agency for Healthcare Research and Quality. Below that, you’ll find a really interesting lecture from a Health Care Disparities Class at Case Western Reserve University from Professor Insoo Hyun. The video is courtesy of the Case Center for Reducing Health Disparities and their well produced blog and resource center.

As for the studies and numbers, though just a small sampling, I’ll let them speak for themselves:

Identifying Disparities in Care

Access to Primary Care

Primary care is the underpinning of the health care system, and research studies have shown that having a usual source of care raises the chance that people receive adequate preventive care and other important health services. Data from AHRQ’s Medical Expenditure Panel Survey (MEPS) reveal that:

• About 30 percent of Hispanic and 20 percent of black Americans lack a usual source of health care compared with less than 16 percent of whites.
• Hispanic children are nearly three times as likely as non-Hispanic white children to have no usual source of health care.
• African Americans and Hispanic Americans are far more likely to rely on hospitals or clinics for their usual source of care than are white Americans (16 and 13 percent, respectively, v. 8 percent).

Diagnosis and Treatment

Race and ethnicity influence a patient’s chance of receiving many specific procedures and treatments. Of nine hospital procedures investigated in one study, five were significantly less common among African American patients than among white patients; three of those five were also less common among Hispanics, and two were less common among Asian Americans. Other AHRQ-supported studies have revealed additional disparities in patient care for various conditions and care settings including:

• Heart disease. African Americans are 13 percent less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are whites.
• Asthma. Among preschool children hospitalized for asthma, only 7 percent of black and 2 percent of Hispanic children, compared with 21 percent of white children, are prescribed routine medications to prevent future asthma-related hospitalizations.
• Breast cancer. The length of time between an abnormal screening mammogram and the followup diagnostic test to determine whether a woman has breast cancer is more than twice as long in Asian American, black, and Hispanic women as in white women.
• Human immunodeficiency virus (HIV) infection. African Americans with HIV infection are less likely to be on antiretroviral therapy, less likely to receive prophylaxis for Pneumocystis pneumonia, and less likely to be receiving protease inhibitors than other persons with HIV. An HIV infection data coordinating center, now under development, will allow researchers to compare contemporary data on HIV care to examine whether disparities in care among groups are being addressed and to identify any new patterns in treatment that arise.
• Nursing home care. Asian American, Hispanic, and African American residents of nursing homes are all far less likely than white residents to have sensory and communication aids, such as glasses and hearing aids. A new study of nursing home care is developing measures of disparities in this care setting and their relationship to quality of care.

Looking Beyond Income and Insurance

Disparities in health care are often ascribed to differences in income and access to insurance. Research has shown these to be important, but by no means the only factors. For instance, the proportion of Hispanic Americans with a usual source of care has declined substantially over the past decade (from 80 percent in 1986 to 70 percent in 1996). Insurance coverage has also declined, and the lack of insurance in some groups is dramatic (among Hispanic men, for instance, 37 percent have no health insurance). Nonetheless, declines in insurance coverage explained only one-fifth of the change in access to a usual source of care.

In another recent study, AHRQ-funded researchers in Boston examined the quality of care provided to hospital patients with congestive heart failure or pneumonia. Quality of care was measured both by physician review and by adherence to standards of care. The researchers found no difference in quality of care for patients from poor communities compared with other patients, after adjusting for other factors. They did find, however, that African American patients received a lower quality of care than white patients.

Physician Decisionmaking

A small study of physicians’ decisions about whether to refer patients for cardiac catheterization, a diagnostic procedure for heart disease, provides supportive evidence that factors other than insurance and income can influence the quality of care people get. This study, which used actors portraying similar economic backgrounds, found that black women were significantly less likely than white men to be recommended for referral, despite reporting the same symptoms. (Differences between other groups studied were not statistically significant.)

Hospital Characteristics

In the Boston study of the quality of care, quality for African American patients was lower in nonteaching than in teaching hospitals. In another study, white patients were more likely than Hispanic and African American patients to receive invasive cardiac procedures in hospitals performing a high volume of such procedures, a factor strongly associated with the quality of cardiac care.

Secretary of State Hillary Clinton on the Global Health Initiative

This C-SPAN report is worth considering: “Secretary of State Hillary Clinton spoke at Johns Hopkins University’s School of Advanced International Studies on the Obama Administration’s Global Health Initiative. She discussed the six-year, $63 billion investment that focuses on improving the health of women, children and newborns throughout the world.”

You can see the video (or the transcript) by clicking on the picture.

Global Inequality & Access to Health Care

According to a recent study in The Lancet, “The world’s wealthiest two billion people get 75 percent of all the surgery done each year, while the poorest two billion get only 4 percent and often die or live in misery as a result.” It’s a striking fact; how are we to interpret it?

There are two metanarrative accounts of the relationship between inequality and health care. On a Whiggish, optimistic view, vast inequality can generate the capital necessary to fund investment in innovative health care technologies. Scholars like Richard Epstein have celebrated both general economic inequality and unequal access to health care particularly because, they claim, buying power at the top promotes investment in medical advances. On this view, innovations in the wealthy world can diffuse throughout lesser developed regions. Moreover, the rich can also subsidize the poor locally, paying for infrastructure that serves a broader community.

Interpreted less charitably, inequality enables the well-off to bid away resources and opportunities from the poor. Richer nations and persons may snap up limited resources; for instance, in 2009, Jeanne Whalen at the Wall Street Journal wrote an article entitled “Rich Nations Lock In Flu Vaccine as Poor Ones Fret:”

A scramble among wealthy nations to guard against a swine-flu pandemic is raising concerns that billions of people in poorer countries could be left without adequate supplies of vaccine. . . . The emerging battle between the haves and have-nots underscores a major weakness in the global health system: Pharmaceutical companies have severely limited capacity to produce flu vaccines in emergencies.

Inequalities can be even more stark at the R&D phase. If an anti-baldness cure can generate billions of dollars in revenue while a new therapy for tuberculosis only generates hundreds of millions, for-profit pharmaceutical companies may well have a fiduciary duty to invest scarce research dollars in the unhirsute rather than the truly unhealthy.

Lawrence Gostin’s recent article “Redressing the Unconscionable Global Health Gap” offers some practical ways of addressing these disparities:

The international community is deeply resistant to taking bold remedial action — more concerned with their geostrategic interests than the health of the poor. The scale of foreign aid is both insufficient and unsustainable and fails to address the key determinants of health. As a result, the world’s distribution of the “good” of human health remains fundamentally unfair, causing enormous physical and mental suffering by those who experience the compounding disadvantages of poverty and ill health.

Lest we dismiss such inequalities as “not our problem,” Thomas Pogge’s sobering new book elaborates on his earlier argument that wealthier nations are responsible for the plight of the poorest:

[P]olitical and economic inequalities are rising dramatically both intra-nationally and globally. The affluent states and the international organizations they control knowingly contribute greatly to these evils — selfishly promoting rules and policies harmful to the poor while hypocritically pretending to set and promote ambitious development goals.

Both Pogge and Gostin’s work should guide policy responses to the extraordinary disparities exemplified in the Lancet story. As I continue to study fractal inequality in access to medicine, I will be sure to consult their proposals for a more just world. I also hope to see proposals for taxation of “medical tourism” that would redirect at least some of the funds from overseas patients to infrastructure that would support underserved patients in the regions they visit.

Caring for Dogland

I always applaud health scholarship that incisively examines inequalities of access in the United States. However, sometimes it’s important to contextualize that work by emphasizing the degree of global inequality that makes even the poor in the US relatively well off by world standards. The following passage from Korzeniewicz & Moran’s 2009 book, Unveiling Inequality gives some sense of the divergence:

The magnitude of global disparities can be illustrated by considering the life of dogs in the United States. According to a recent estimate . . . in 2007-2008 the average yearly expenses associated with owning a dog were $1425 . . . For sake of argument, let us pretend that these dogs in the US constitute their own nation, Dogland, with their average maintenance costs representing the average income of this nation of dogs.

By such a standard, their income would place Dogland squarely as a middle-income nation, above countries such as Paraguay and Egypt. In fact, the income of Dogland would place its canine inhabitants above more than 40 percent of the world population. . . . And if we were to focus exclusively on health care expenditures, the gap becomes monumental: the average yearly expenditures in Dogland would be higher than health care expenditures in countries that account for over 80% of the world population. (xv)

Certainly public policy should take into account the problem of relative deprivation, which can lead to a much worse subjective experience for those at the “bottom” of the SES distribution in a rich country than those in the middle in a poorer country. Nevertheless, the statistics above help us understand why drug companies, already frustrated by low ROI in R&D, might shift from researching cures for tropical diseases to focusing on pet anxiety medications.

Kennedy Steps Down, Obama Steps Up EMR Spending Plan, and Study Shows Disparity in the Treatment of Women

Ted Kennedy steps down from the Senate Judiciary Committee to focus on Health Care reform.
“As chairman of the Senate Health, Education, Labor and Pensions Committee, I expect to lead a very full agenda in the next Congress, including working with President Obama to guarantee affordable health care, at long last, for every American,” said Kennedy. Read more here.

Obama announces plan to include Medicaid and Health Information Technology in stimulus package. Set for January?
Although some “congressional sources have expressed skepticism” about the ability to pass legislation of such magnitude so quickly, “top economic advisers to Obama and congressional Democrats hope to complete work on the package in January to allow Obama to sign the legislation when he takes office on Jan. 20, 2009.”
One aspect of the proposal, computerizing medical records to coordinate efforts and avoid redundancies is said to enjoy “bipartisan support in Congress,” though privacy concerns have been a matter of contention. Read more here.

A Study which examined the hospital treatment for 78,254 heart attack victims shows a disparity in treatment and results for men and women with massive heart attacks.
The study showed a greater mortality rate for women with massive heart attacks, and a lesser likelihood for women to receive recommended medicines such as aspirin within the crucial 24 hour time frame. The study also showed that women were less likely to get treatment to restore blood flow, or that it wasn’t given quickly enough. Read more here.