Advancing equity in healthcareBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1617 (Published 01 April 2015) Cite this as: BMJ 2015;350:h1617
- Marshall H Chin, Richard Parrillo family professor of healthcare ethics
- 1 Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007 Chicago, IL 60637, USA
Healthcare reforms in Massachusetts that began in 2006 might foreshadow the effects of President Obama’s national Affordable Care Act and have been subject to intense scrutiny as a result. Two linked studies of the reforms in Massachusetts indicate that expanding of health insurance is helpful but not enough to eliminate important social and ethnic disparities in care and outcomes.1 2 Hanchate and colleagues (doi:10.1136/bmj.h440) studied joint replacement surgery, an effective treatment for end stage joint disease that reduces pain and improves function and quality of life3 but is underused among patients on low incomes and those from racial and ethnic minority backgrounds.4 In their study, greater access to health insurance in Massachusetts was associated with increased rates of knee and hip replacement surgery among Hispanic and black people compared with white people but was not associated with increased rates among people on low incomes relative to richer people.1 In a second study, McCormick and colleagues (doi:10.1136/bmj.h1480) found no association between Massachusetts healthcare reforms and reduced racial and ethnic disparities in admissions to hospital for diseases such as asthma, diabetes, and heart failure. Many admissions for these “ambulatory care sensitive conditions” are preventable if patients have access to high quality outpatient care.2
Procedures such as joint replacement are dependent on the preferences of patients as well as the actions of clinicians. Appropriate use of joint replacement surgery depends on two steps. First, patients must have access to the healthcare system. Massachusetts’ reforms expanded eligibility for health insurance and reduced out-of-pocket costs for patients, critical for costly surgical operations.1 Second, even in countries that already have universal health insurance,5 clinicians must offer surgery to patients who need it,6 identify their preferences, and facilitate their decisions.
Clinicians, however, must do more than simply ask about symptoms and functional status, describe joint replacement surgery along with the likely benefits and harms, then ask the patient what he or she wants to do. Clinicians must identify and overcome the many barriers to surgery faced by racial and ethnic minority populations, including mistrust of the healthcare system and previous negative healthcare experiences.7
As part of this process clinicians should encourage patients to tell their stories (“Tell me how arthritis affects you during a typical day”), ask open ended questions to explore life experiences that shape a patient’s perspective (“What has been your experience, or the experiences of your family and friends, with surgery?”), and engage in reflective empathetic listening and discussion (“Tell me more about that bad experience with your prior surgery”). Clinicians should tailor care to each patient, while being aware of sociocultural influences such as community attitudes.8 For example, among some African-American patients, “telling my story and being heard” is a particularly important part of the shared decision making process.9
Why healthcare reform in Massachusetts seemed to reduce disparities in joint replacement by race and ethnicity but not income is unclear. If low income patients bought cheaper insurance plans that required large deductible payments before coverage began, they might still defer non-emergent procedures such as joint replacement for longer than wealthier patients with more comprehensive insurance.10 Low income, rural residents might have health insurance but lack access to orthopedic surgeons because of maldistribution of doctors.11 Many patients from racial and ethnic minority backgrounds, however, live and work in urban areas with more orthopedic surgeons.
In fact, care of racial and ethnic minority patients in the United States is concentrated in a relatively few hospitals (sometimes referred to as “safety net hospitals”), and they need special attention.12 Some policy makers argue for a free market approach: publicly report the quality of care and outcomes of hospitals’ joint replacement services, stratifying by the race or ethnicity and socioeconomic status of patients, to help consumers identify the best places to get surgery and also to encourage hospitals to improve their care.13 Many patients, however, will continue to receive care in safety net settings, as reported among black patients in the study by Hanchate and colleagues.1 Geographic proximity, community norms (“the county hospital is where we get our care”), and the many uninsured and underinsured patients in the US drive use of safety net hospitals, which need extra resources to provide optimal care.
Next, consider admissions to hospital that can be prevented by high quality ambulatory care. The apparent failure of Massachusetts’ healthcare reform to reduce racial and ethnic disparities in preventable admissions is a striking reminder that improved access to care must be accompanied by improvements in the quality of care for vulnerable populations to achieve equity. Generic efforts to improve the quality of care and financial incentives to reduce overall readmissions to hospital often do not reduce disparities and could worsen disparities if they penalize safety net institutions caring for vulnerable populations.14 15 Successful interventions to reduce racial and ethnic disparities for ambulatory care sensitive conditions such as asthma, cardiovascular disease, and diabetes target different drivers of these disparities and include culturally tailored care, nurse managed teams that closely monitor patients at home and personalize treatment, community health workers and patient navigators who bridge the divide between the patient’s world and the healthcare system, and engagement of families and communities to help patients manage their health.13 16 17 18 19 20 Policy makers should create financial incentives that reward outstanding care, excellent communication, and shared decision making with patients, improved quality of life and function, and shrinking disparities. They should also provide additional support to healthcare organizations caring for vulnerable populations.12 13 15
Expanding health insurance coverage is a critical step toward reducing health disparities. Patients must be able to access and afford healthcare. These two studies examining use of joint replacement and preventable admissions to hospital, however, confirm that extra insurance coverage alone will not eliminate all differences in care and outcomes.1 2 To achieve equity in the use of effective treatments we must make care truly patient centered by improving our communication and shared decision making with patients and the ways we deliver and incentivize care.12 13
Cite this as: BMJ 2015;350:h1617
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.
Provenance and peer review: Commissioned; not externally peer reviewed.