OP-ED | Health Disparities Are Real and New Payment Schemes Are Probably Making Them Worse
Connecticut is a very healthy place; we rank fifth healthiest among states. But not all state residents share in that good fortune; too many suffer from health inequities. Good people across the state are doing important work promoting better health for everyone. However some emerging policies, both government and private sector, are working at cross purposes to those efforts.
The chief policy risk to health equity is provider risk — the latest shiny new thing in how we pay for healthcare.
Despite our overall health, for health disparities Connecticut ranks at the bottom, 43rd among states. Low-income Connecticut residents are five times less likely to be in good health than higher wage workers. Blacks in Connecticut are 70 percent more likely to have diabetes than whites; Hispanics are 41 percent more likely to suffer from asthma. Low-wage workers pay more, not just as a percent of their income but more dollars, for skimpier health benefits at work.
Studies have found that non-white patients receive less care for heart disease than whites. Black men are less likely to receive chemotherapy and radiation for prostate cancer and black women are more likely to die after a breast cancer diagnosis. It’s estimated that health disparities cost the U.S. economy $135 billion each year due to excess medical care and lost productivity. Inequities are not limited to people of color or low-income residents. Health disparities based on gender, sexual orientation, age, gender identity, disability status, and physical appearance — such as height or weight — are well-documented. In possibly the worst disparity, people with serious mental illness die 15 to 30 years younger than the rest of us. Disparities are common and serious.
While not all causes of inequality are known, an important contributor is implicit bias. Subconscious false beliefs about groups of people are widespread and affect the healthcare patients receive. Black patients are systematically under-treated for pain management compared to whites. A study found that a surprising number of providers believe that blacks have a higher tolerance for pain than whites and that false belief correlates with lower pain treatment recommendations.
Providers are no more or less subject to false beliefs than the rest of us, but their biases impact healthcare. Implicit bias is automatic and unconscious, but there are promising interventions to address the problem, including effective training for both new and practicing providers, examining healthcare institutions’ processes and blind spots, and identifying errors and following up to fix them for the future. Progressive Connecticut providers and institutions are implementing these and other innovations to close our state’s equity gap.
Unfortunately, policies being implemented in Connecticut to control rising healthcare costs could undermine that work.
The new and very controversial policies shift incentives to reward providers for lowering the cost of their patient’s care. This could be done the right way, by keeping people out of the hospital and reducing extra tests, but in the past savings have been generated by denying necessary care and dumping less-lucrative patients. Already struggling to access care, underserved Connecticut residents are at even higher risk of poor outcomes under the new model.
The Institute of Medicine, in their Unequal Treatment report, found that, “Financial factors, such as capitation and health plan incentives to providers to practice frugally, can pose greater barriers to racial and ethnic minority patients than to white patients, even among patients insured at the same level.”
Connecticut policymakers acknowledged this concern and created the Equity and Access Council. The Council made detailed, specific policy recommendations to protect people from underservice and patient dumping, especially those suffering from disparities. Unfortunately, the recommendations have been largely ignored by both state and private plans. It’s just easier to hope for the best and collect the savings.
In selling these new payment models, proponents are claiming the opposite effect — that they will reduce disparities naturally. Proponents have rejected calls for oversight and monitoring for harm. They have even failed to notify consumers of the risks in required notices. They argue that providers and large health systems could use their profits from the new model to improve access to reduce disparities, but they also acknowledge that it isn’t happening that way.
If large healthcare institutions chose to devote their current profits to the issue, we might not have a problem. Even if they wanted to, expecting providers and large institutions to solve the problem of disparities is unrealistic. Mistrust of the healthcare system and providers has risen sharply in recent decades, especially in low-income and minority communities, undermining the foundational doctor-patient relationship. Rewarding providers for lowering the cost of care will only add to that mistrust.
While more research on disparities is needed, there are options that work. Training on implicit bias and monitoring for its impact are working and need to be supported. Proven public health initiatives such as promoting healthy behaviors like exercise, expanding access to healthy food, helping people quit smoking, and expanding healthy housing save money for everyone, especially the underserved. To control costs, we need data to know where the problems are, and where they aren’t. Simplistic payment reform models, that aren’t working in other states, are not the answer. And health disparities are too important to risk it.
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