Practicing Medicine While Black

By Kip Sullivan, J.D.
The Health Care Blog, November 9, 2017

The managed care movement thrives on misleading words and phrases. Perhaps the worst example is the incessant use of the word “quality” to characterize a problem that has multiple causes, only one of which might be inferior physician or hospital quality. To illustrate with a non-medical analogy, no one would blame auto repair mechanics if 50 percent of their customers failed to bring their cars in for regular oil changes. We would attribute the underuse of mechanics’ services to forces far beyond the mechanic’s control and would not, therefore, refer to the problem as a “quality” problem.

But over the last three decades it has become acceptable among American health policy experts and policy-makers to characterize any measurement of under- or over-use of medical care, or any measurement of a medical outcome, no matter how poorly adjusted to reflect factors outside provider control, as an indication of “quality.” The widespread, inappropriate use of “quality” long ago set off a vicious cycle. It helped spread the folklore that the quality of America’s doctors and hospitals is awful, and that in turn was used to justify taking even more crude measurements of quality, and so on.

In the early 1990s when the measurement craze was limited to a few “quality” report cards, and grades on those report cards were not used to punish or reward doctors and hospitals, the craze posed less risk to providers who treated a disproportionate share of the poor and the sick. But over the last 15 years, inaccurate “quality” grades on report cards have been linked with financial penalties and rewards. Payment schemes that link rewards and punishments to quality scores were dubbed “pay-for-performance” (P4P) circa 2003. Payment schemes that link rewards and punishments to both quality and cost scores, which began to materialize in the late 2000s, were dubbed “value-based purchasing” (VBP) schemes. (“Value” implies both quality and price have been taken into account). These VBP schemes go by various names, the most important being “accountable care organization” and “medical home.” MACRA is one big VBP scheme.

A growing body of research indicates P4P and VBP schemes (I will refer to both from now on as VBP schemes) pose a much greater threat to the health of poorer and sicker Americans than the old report cards did. They do so because they pose a much greater threat to the financial health of the providers who treat poorer and sicker Americans. Because minorities represent a disproportionate share of our nation’s sickest and poorest, and because the responsibility for treating minorities falls disproportionately on a few clinics and hospitals, many of them staffed by minority health care professionals, VBP schemes punish minority providers for no reason other than that they see more minority patients.

In this article I will document what I have just said by focusing on black doctors as well as hospitals and ACOs that serve a large number of black patients. I will argue that those who promote VBP are guilty of racial profiling – punishing black doctors and other providers who treat a high proportion of black patients and, ultimately, black patients. We will see that three intractable conditions guarantee that VBP penalizes black providers and their patients:

(1) Black physicians, and a small number of hospitals, treat a disproportionate share of black patients;

(2) black patients tend to be sicker and poorer than white patients, which means the clinics and hospitals that treat a disproportionate number of them have to spend more on them and yet have fewer resources to do that, and are therefore less likely to score well on cost and quality measures; and

(3) administrators of VBP schemes are incapable of adjusting quality and cost scores accurately to take into account factors outside provider control, including the lower health status, lower incomes, worse insurance, worse access to transportation, and greater exposure to stressors such as crime and food insecurity suffered by black Americans.

Note that I am not criticizing measurement per se. Measurement is essential to quality improvement in every field of human endeavor. I’m criticizing inaccurate measurement and the reckless use of inaccurate measurement.

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There are many problems in our health care system. There are many problems in our nation. And they inevitably interact.

At PNHP we tend to focus on our health care financing system and the interaction it has with the delivery of health care. Application of solid health policy is important in correcting the deficiencies in these interactions. But today’s message suggests that health policy science may still be in its primitive stages, not so much because of the lack of intellect in the health policy community but rather because of lack of enlightenment that has been suppressed by the memes of the free market approach to our nation’s problems, expressed in the concept that the government’s legitimate role is merely to help the private marketplace work.

Of course the needs unmet by the marketplace could not be ignored and thus public programs such as Medicare for the elderly and Medicaid for the poor were enacted. Yet we are shoving the beneficiaries of these programs into market models such as private Medicare Advantage plans and private Medicaid managed care organizations. We are also inundating the delivery system with nebulous market concepts such as shifting from volume to value – an ill conceived concept with which we are moving rapidly forward with implementation when the policy science studies to date have failed to give much support for such concepts.

In the marketplace resources are allocated based on the prospect for optimal business success; health care is distributed based on ability to pay. In publicly administered health programs resources are distributed based on need. Public funds are already used to pay for 60 to 70 percent of health care in the United States, yet we place control of much of our resources in the private sector.

What does this have to do with practicing medicine while black? It should be obvious. The private sector is not inclined to direct its resources to endeavors that do not provide greater revenue opportunities, whereas publicly administered programs distribute based on need – not only for health care but for correction of all of the other social deficiencies that have resulted in worse outcomes for the poor, a sector disproportionately represented by minorities.

A quick look at the current tax proposals tell us where we are. The greatest economic problem we face today is the transfer of income and wealth from the struggling masses to the plutocrats at the top. Yet the proposals before Congress would increase that upward transfer when the need is for public policies to improve social justice. This need screams out for progressive public financing rather than the regressive policies proposed.

We need to get our public priorities in order. We should be rewarding black physicians who dedicate themselves to caring for black patients and other ill-served populations who are sicker and poorer and thus a greater challenge to care for. Instead we penalize these virtuous physicians through payment reductions based on quality scores designed for business models rather than patient service models. Yes, we punish them. That isn’t right.

Changing to a more equitable financing system – an improved Medicare for all – is crucial, but it is only a first step. Since it is imperative that we also address these other social and economic issues, we’ve got a lot more work to do.

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