By Suhas Gondi
in-Training, July 18, 2016

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

– attributed to Martin Luther King, Jr.

[PNHP note: The “Letter to our Patients on Racism” cited in the last paragraph of this article has been signed by more than 3,000 physicians and medical students as of July 19.]

In December of 2014, one week after the non-indictment in the case of Michael Brown, in-Training published an article entitled “A Lack of Care: Why Medical Students Should Focus on Ferguson.” In it, Jennifer Tsai argued that the systemic racism rampant in our law enforcement and criminal justice systems also permeates our health care system, affecting both access to care for black patients and the quality of care black patients receive. Lamenting that the medical community was largely absent from the Ferguson controversy, she cited startling statistics of disparities in health and health care as part of her call to action. In light of the events last week in Louisiana, Minnesota, and Texas, it’s time to revisit this message.

The deaths of Alton Sterling and Philando Castile re-galvanized the Black Lives Matter movement, which began in Ferguson and has since spread to every corner of this country. Besides spurring impassioned advocacy, they serve as a reminder to us all of the systemic racism is still ingrained in our society. The seemingly innate biases so many of us carry have not eroded — they still abound in our daily lives and the world around us.

These events should also serve as a reminder to every physician, medical student and premedical student of the ways in which our health care system is subject to those biases. While the white coat has come to represent the profession’s humanity and morality, the evidence decisively shows it is not impermeable to prejudice.

The published literature supporting the existence of racial disparities in health care is vast. The seminal report on the subject was published in 2002 by the Institute of Medicine (IOM), which found that a large body of research highlighted the presence of real disparities. It concluded that even after controlling for insurance status, income, age and severity of conditions, minorities receive a different level of care than white patients. They were less likely to be prescribed appropriate cardiac medications, undergo bypass surgery or receive kidney dialysis and more likely to undergo “less-desirable procedures” such as a lower limb amputation due to complications from diabetes.

Since 2002, when the IOM report brought widespread attention to such disparities, researchers have published hundreds of studies that shed more light on the differences in the way black and white patients are cared for by their doctors. One analysis published two months ago examined nationwide trends for racial disparities in cardiac interventions after a heart attack before and after the 2002 IOM report, finding that disparities persisted well after the report. Some of these disparities have been well-studied and widely cited. Black patients face a two-thirds higher risk than white patients of not receiving an analgesic (a pain medication) when in the ER for a long-bone fracture, even after controlling for confounding variables. Minorities are also less likely than white patients to be prescribed opioid medications for a comparable set of symptoms. This disparity is most significant with conditions that have less objective findings, like a migraine. When patient assessment and test results do not point to a conclusive diagnosis, the effect of inherent biases on clinical decision-making is greater.

The federal government has also published its own studies on the topic. The 2015 National Healthcare Quality and Disparities Report reported that black patients received worse care than whites for about 40 percent of quality measures, a statistic almost identical to the 2011 report, the first annual publication. Even in special populations, such as senior citizens over the age of 65, with similar health problems and the same insurer, racial disparities persist. Black Medicare beneficiaries are, on aggregate, less likely to receive recommended care than white ones.

These differences, along with variation in the social determinants of health across race, contribute to the serious health inequities observed between blacks and whites. While the gap in life expectancy has narrowed over the past several decades, a white baby born today can still expect to live, on average, four years longer than her black counterpart. Although disparities in health outcomes such as longevity are largely the product of structural factors, it is difficult to believe that the lower quality of care delivered to blacks versus whites does not play any role in explaining these gaps.

Clearly, the medical community has a stake in the national conversation around systemic racism and police brutality re-launched by the deaths of Sterling and Castile. The evidence overwhelmingly suggests that physicians are just as vulnerable to the inherent biases that affect police officers. The biases that are blamed for higher arrest rates among blacks for crimes that whites commit more often are the same biases that lead to black patients receiving timely and aggressive intervention far less often than white patients in a cardiovascular emergency. These are distinct symptoms of a single underlying cause. The assumptions that cause well-intended police officers to stop-and-frisk blacks five times as frequently as whites are also harbored by physicians. These ingrained stereotypes are not profession-specific. They are universal.

The tragic deaths of five police officers in Dallas last week points to another parallel with the medical establishment. The tension between police officers and the communities they protect is mirrored by a tension between physicians and the patient populations they care for. The skepticism of black patients toward the medical community, especially in the area of clinical research, is well-documented. A Johns Hopkins study reported that a full quarter of black patients, 10 percent more than whites, believe that their physician would ask them to participate in a study even though the study might harm them. 6 percent more blacks than whites felt their physician would willingly expose them to unnecessary risk. Most striking, almost 60 percent of black participants, well over twice the proportion of whites, thought that physicians use medications to experiment on people without the patient’s consent. Evidently, doctors and police officers share the challenge of serving populations that sometimes put little faith in them and their professional authority.

Just as the distrust that many black men have for police is rooted in America’s history of racial profiling, the lack of trust towards physicians has been shaped by a long history of exploitation and experimentation on black bodies. The Tuskegee syphilis trial, which began in the early 1930s and lasted forty years, is perhaps the most infamous example. Government researchers deceived black patients suffering from syphilis into believing they were receiving treatment when, in fact, they were being observed to gain insight into the natural course of the disease. The legacy of Tuskegee is still reflected in the widespread mistrust that undermines doctor-patient relationships across the country.

In a national town hall this week, President Obama spoke on how trust between a community and its police officers is critical for police departments to do their job of serving and protecting. Distrust leads to bad outcomes, often in the form of unwanted violence. The same is true in medicine, except bad outcomes mean poor health. Evidence shows that high levels of distrust of their physicians among black patients contributes to health disparities by causing reduced utilization of preventive services, relative to whites. These services include routine checkups and preventive screening (e.g. mammograms), the most cost-effective and valuable health care services in promoting and preserving health. Distrust also discourages blacks from participating in clinical trials, which hinders the research of therapies targeted at African Americans and intensifies disparities in the quality of health care. Even in the absence of any true discrimination, perceived discrimination, perhaps based on statistics showing differences in how blacks and whites are treated, is associated with poorer health.

Physicians whose priorities are their patients’ health ought to pay attention to disparities in care, the mistrust those disparities breed and the poor health outcomes that are observed as a result. This pernicious cycle begins with subjective biases and often causes objective harm to black patients, perpetuating disparities in care and health.

Black Lives Matter is highlighting and combating the biases that are at the root of unequal policing practices. A medical community that is often impartial to issues outside its purview might find it easy to ignore such a movement. But that would be a grave mistake.

We cannot achieve equity in health care without achieving equity in policing. Both are symptoms that can only be addressed if we treat the underlying cause. We must acknowledge and combat our collective biases in all facets of life to truly cure the disease. Just as the problem is not health care-specific, nor is the solution. We must strive broadly for social justice, not only in the clinic but also in our communities, our neighborhoods and our police departments.

Closing racial disparities is a societal endeavor, and engaging with Black Lives Matter is a step towards that common goal for police officers and physicians alike. If we join the activism all around us and if we stand with this movement for social justice, we can begin to tackle the implicit prejudices that result in a black man getting Tylenol when he needs an analgesic and that result in the fatal shooting of that same man in the absence of any crime. We can begin to heal the underlying problem.

Everyone has a part to play. Physicians can do the challenging work of looking closely at their own patterns of prescribing and treating, searching for biases that are often imperceptible at an individual level but contribute to collective disparities. Medical students and residents can critically reflect on the education they are receiving, if it is imbuing them with stereotypes and ensure they are honing the skills to combat systemic racism. Premedical students, like myself, ought to enter our training understanding the issues at hand and being aware of the unconscious prejudices we, our peers and our mentors hold. It is difficult for us to be critical of the medical guild into which we are working so hard to gain entry, but we are the future of the profession and a necessary part of any solution.

It is natural to feel helpless in the face of the startling statistics of health care disparities and the horrific events of last week. However, there is reason to hope. Over the last few years, the medical community has shown signs of change. Nationwide medical student die-ins in protest of police brutality were a beginning, giving rise to national organizations such as WhiteCoats4BlackLives that consistently advocate for a more equitable future. Doctors for America has taken on racial disparities. Medical leaders, such as New York City’s health commissioner, have joined in the call to action, insisting that the medical community ought “not sit on the sidelines.” Medical education, too, is changing. The American Association of Medical Colleges has spearheaded efforts to incorporate diversity, inclusion and cultural competency as a core value of our nation’s medical schools. Even at the premedical level, the new MCAT encourages studying sociology and explicitly tests knowledge of the disparities in health and health care in an effort to reduce these disparities in the long run.

Perhaps most promising is the recent “Letter to Our Patients on Racism” which has been signed by over 2,600 physicians and medical students. Its authors acknowledge that “historically, physicians as a group have not yet taken adequate responsibility for confronting racism, in our work or outside of it.” They make five commitments: 1) to support Black Lives Matter, 2) to dismantling the structural racism embedded in our healthcare system, 3) to learn how to provide trauma-informed care, and to teach this approach to our students, trainees, and fellow providers, 4) to healing communities ravaged by discriminatory criminal justice practices through engaging public health systems and 5) to using our power as constituents and leaders to insist that every major medical society and association develop a policy on racial justice. These are difficult promises to fulfill, and they require that every one of us do our part.

Suhas Gondi is a pre-medical student at Washington University in St. Louis (Class of 2017). He is pursuing a Bachelor’s degree in Biology with a Neuroscience focus alongside minors in Economics and Healthcare Management. In addition to becoming a physician, he is interested in the systemic problems in American health care (e.g. cost, access, quality) and how we can use innovation and policy initiatives to solve them. A local of the Washington, D.C. metropolitan area, he hopes to pursue leadership in public service at the intersection of government and health care.

http://in-training.org/black-lives-matters-matter-medical-students-familiar-message-revisited-11747

As conservatives and congressional Republicans seek to dismantle the Veterans Health Administration, members of the commission called for giving veterans more private-sector options.

By Suzanne Gordon
The American Prospect, July 12, 2016

After almost a year of meetings and hearings, the Commission on Care has finally issued its report on the future of the Veterans Health Administration. “Care delivered by the VA,” the congressionally mandated report states, “is in many ways comparable or better in clinical quality to that generally available in the private sector.”

But with problems in accessing services, in variations in care, and in the managerial culture at various facilities, the commission believes that the major remedy lies not in outright privatization but in giving veterans more private-sector options, a finding that veterans groups fear may also weaken the decades-old system.

One of the commission’s most complex and potentially problematic recommendations involves the creation of a “VHA Care System,” that would integrate private-sector providers into a VHA-supervised network. The network would service only those veterans eligible for VHA services. Currently, about nine million veterans have been able to establish VHA eligibility; that is, they have health problems connected to their military service or a low-enough income to qualify for enrollment.

The commission recommended that veterans who are VHA-eligible would choose a primary care provider who, in turn, would refer them to specialists. These primary care doctors or specialists could work within the VHA or go outside the VHA to be providers who contract with the agency.

The VHA would be required to create a network that includes all providers who take care of veterans. The agency would have to screen and then contract with community or private-sector providers and ensure that those providers use information-technology systems that are compatible with the VHA’s networks. The VHA would also have to make sure that those providers understand military culture, and would be responsible for coordinating the care veterans receive and helping them navigate the system.

Coordinating care will not be easy. The commission found that veterans who are treated in the VHA do receive coordinated care while those with private plans, Medicare, or TRICARE receive care that is of “lower quality, threatens patient safety, and shifts costs among payers.”

The commission also suggests revising the byzantine VA eligibility requirements that deny benefits to veterans who were “dismissed from military service with an other-than-honorable discharge because of actions that resulted from health conditions (such as traumatic brain injury, posttraumatic stress disorder, or substance use) caused by, or exacerbated by, their service.”

The VHA needs more funding for competitive salaries, which will help recruitment and retention of professional staff. Since there are nationwide shortages of certain health-care professionals, recruiting will not be easy.

The commission estimates that over the next few decades, about 40 percent to 60 percent of veterans will receive some, if not all, private-sector, health-care services. Treating fewer patients could significantly compromise VHA care if health-care providers cannot maintain their clinical skills.

Those developments could also discourage health-care professionals from working in or staying with the VHA, which could lead to closing some facilities. “Reductions in volume of care within VA facilities, and potentially adverse effects on quality” are not addressed, the report notes.

The commission’s recommendations are a product of a fractured political divide within the commission itself. Members who supported the VHA constantly fought with hospital-industry executives as well as representatives of the conservative Koch brothers–funded Concerned Veterans for America (CVA), the so-called Strawman group, which advocated dismantling VHA. Darin Selnick and Stewart Hickey, commissioners who were both connected to CVA, refused to sign the final report. They viewed it as weak on privatization.

Two other commissioners had differing views. Michael Blecker, a Vietnam veteran and executive director of Swords to Plowshares, a San Francisco–based veterans organization, refused to sign the document because of serious concerns that the proposed health-care system “would threaten the viability of VA care for millions of veterans who rely on it.” However, Philip Longman, author of Best Care Anywhere: Why VA Health Care Would Work Better For Everyone, one of the few studies of the veterans health-care system, supports the plan with some reservations. He believes it could bring more veterans into the VHA system and improve the quality of care.

To provide a stronger system, Congress would have to allocate more funds to allow the VHA to hire the necessary staff to provide direct care and handle all the demands of integrating private-sector contractors into the veterans health-care system. Without these resources, the integrity of the VHA will be compromised and the agency would face blame for poor care that veterans receive.

The pending VHA privatization bills proposed by Senator John McCain, an Arizona Republican, and Representative Cathy McMorris Rodgers, a Washington Republican (supported by Representative Jeff Miller, a Florida Republican and chair of the House Veterans Affairs Committee), obviously would not give the agency that leeway. Neither would Donald Trump’s plan to give all veterans vouchers for use in the private sector, which would effectively eliminate the VHA. Announced Tuesday, the plan has already sparked outrage from veterans groups and unions.

The news media will also influence future perceptions of the agency. Mainstream media outlets like CNN that use headlines like “Billions spent to fix VA didn’t solve problems, made some issues worse” to describe the commission report help create a VHA-is-broken-beyond-repair narrative. Although The New York Times has been extremely critical of the VHA, its recent editorial opposing VHA privatization could turn what many veterans groups see as an anti-VHA bent in the national news media.

Finally, the commission report stresses that the VHA currently delivers some of the best care anywhere. Rather than just talking about teamwork, most VHA providers actually work in teams, communicate with one another on electronic medical records, and help patients avoid unnecessary and dangerous overtreatment. The VHA also provides some of the best services for mental health, rehabilitation, and homelessness in the country.

A plan that contributes to strengthening the VHA and improving the private-sector health-care system would be a positive development for veterans and all the rest of us. But if the deficiencies in the civilian health-care system begin to infect the VHA, millions of Americans will lose out.

http://prospect.org/article/report-vha-care-commission-recommends-privatizing-some-services

By Michael Blecker
San Francisco Chronicle, July 15, 2016

Now that we are in the final stretches of the presidential campaign, it is important to examine both Donald Trump’s and Hillary Clinton’s views on the Veterans Health Administration — particularly the hot-button issue of “expanding choice” — that is, privatizing veterans’ health care.

I served as one of 15 commissioners on the congressional Commission on Care, which last month adopted the dangerous idea of moving toward privatization. That will degrade the Veterans Health Administration’s veteran-centered health care system. I made it clear when I joined the commission that if I thought the results of our work would hurt veterans, then I would not sign the final report.

I didn’t sign.

The commission was appointed by the president and Congress to improve the veterans health care system, not dismantle it. I was one of the very few commissioners who represented veterans who use and depend on the health administration.

The commission’s final report includes 18 recommendations aimed at strengthening the administration, and 17 of them outline solid and bold plans for improvement. The most significant recommendation, however, redesigns the care-delivery system to include private health care providers.

The commission’s recommendation for “choice” was not based on data that show cost savings, improved quality of care, shorter wait times or a belief that veterans’ health care and access will be improved. In fact, independent assessments found that VA care is comparable or even better in clinical quality than private health care. Seventy-five recent studies confirmed this, and yet the commission report does not explain why expanding reliance on lower-quality private health care options will improve veteran care. Ultimately, the decision came down to the fact that the majority of the commissioners were determined to establish a path to privatization.

Privatization would:

Increase costs, because VA doctors are salaried, not incentivized.

Reduce access, because resources will be diverted.

Not improve the quality of care, because it does not ensure that health care providers are well equipped to address veterans’ specific health and cultural needs. For example, fewer than 50 percent of private health care providers regularly screen for PTSD, and fewer than 20 percent are trained to document a veteran’s military history, which can be critical in identifying service-connected health issues.

Not shorten wait times to see a doctor. No data found that wait times in the private sector are any shorter than at the VA. Unlike the VA, the private sector isn’t required to measure wait times.

Dismantle the Veterans Health Care system because, unlike the VHA, the private health care sector has considerable funds dedicated to marketing its services. Economists estimate that “choice” could reduce the patient base by as much as 40 percent. The Veterans Health Administration would have to pay private health care providers to care for veterans, but would not be able to control how providers deliver that care.

When it comes to providing choice to veterans who live more than 40 miles from a VA facility, the VA has been more than willing to enable veterans to use private health care in their communities. Expanding choice in areas like San Francisco, where veterans have access to excellent care at the Fort Miley and Palo Alto veterans hospitals, is not necessary.

Clinton and Trump disagree on private health care options for vets.

Trump said he wants to ensure that “every veteran has the choice to seek care at VA or private care, paid for by our government.” In his 10-point plan for fixing the VA, he states, “The power to choose will stop the wait-time backlogs and force the VA to improve and compete if the department wants to keep receiving veterans’ health care dollars.”

Clinton has said that she wants to restructure the VA but opposes privatization. In her VA platform plan, she states, “From the top leadership to mid-level managers to entry-level employees, everyone at the VA must embody the highest workplace standards. Supervisors must be empowered to suspend or remove underperforming employees in accordance with due process not only for the good of the organization, but in service of our nation’s veterans.”

When I enlisted, I was promised that the nation would take responsibility for the medical and health consequences of military service. We must design our veterans’ health care system for those who need it most, not for those who want it least.

True, operations failures have overshadowed successes in recent years, yet the system is worth saving. The commission’s recommendations related to improving clinical operations, facility and capital assets, governance, health care equity, information technology, supply chain, and workforce management should be implemented promptly. If we adopt the “choice” model, however, we will eviscerate any chance of improving the systems that provide care for more than 9 million veterans.

As a commissioner, a veteran and a lifelong advocate for community-based veteran support services, I have seen the VHA transform into the comprehensive, integrated, wraparound provider of veteran-centered health care that it is now. I do not want to see us move backward.

Michael Blecker is the executive director of Swords to Plowshares, a community-based nonprofit that provides services to 3,000 veterans in the San Francisco Bay Area. To comment, submit your letter to the editor at http://bit.ly/SFChronicleletters.

Weigh in

Tell your congressional representative know that we cannot degrade our nation’s health care system for our veterans.

Tell your political party leaders it is important to improve the operations, not dismantle, the Veterans Health Administration.

http://www.sfchronicle.com/opinion/article/Choice-privatization-will-dismantle-VA-s-8381277.php

James Burdick, MD, proposes a doctor-run single-payer system

By Joyce Frieden
Medpage Today, July 15, 2016

A single-payer healthcare system could work in the U.S., but only if doctors are involved with running it, according to James Burdick, MD.

“When the Clinton health plan failed in late 90s, it started to bother me,” said Burdick, a retired transplant surgeon. “Then I started thinking about how we could make it work. The idea of single-payer wasn’t what I was thinking about — I was thinking about how to make it work, and that meant doctors.”

Burdick, a Harvard Medical School graduate and currently professor of surgery at Johns Hopkins University in Baltimore, has written a book, “Talking About Single Payer: Health Care Equality for America,” to explain his idea. One purpose of the book is to counter peoples’ objections to a single-payer system, in which healthcare costs are paid for by the government and financed through income taxes.

“A little over 50% of the healthcare in this country is provided by government programs now — when you add up Medicare, Medicaid, the VA [Department of Veterans Affairs] and a few others — so it’s not such a wild idea to have the government pay for healthcare,” he told MedPage Today in a phone interview.

Critics say that a single-payer system restricts peoples’ choices in healthcare, but Burdick said that under the current system in which many workers get healthcare through their employers, “the employee is actually getting whatever healthcare package is negotiated by the employer and the insurance company the employer is using, so immediately the choices they might have are interfered with by the negotiation between the employer and the insurance company.”

Under Burdick’s proposal, a quasi-governmental organization called a Health Security Board would be established; it would be overseen by the Department of Health and Human Services but would not be an official government agency. The board would include a variety of providers including physicians, nurses, paramedical personnel, hospital administrator, and laypeople, and its job would be “to oversee the healthcare choices that doctors and their patients make.” Among other duties, the board would decide what would constitute “essential health benefits” to be paid for by the government, as well as help oversee healthcare quality and specify what items need to be incorporated into an electronic health record.

“One of the biggest things from the doctor’s point of view is the remarkably complicated system in place now,” Burdick said. “You may have as many as 1,000 different payers for a group of doctors or for a hospital, and the federal government has another set of rules that are increasingly interfering with ‘best’ clinical practice’ and taking time from helping take care of patients, so those things could vanish if we have the system the way I envision it — the patient goes in, everybody has access, they see their doctor, and all these things [like] billing can be dealt with, without interfering with the doctor-patient relationship.”

The Health Security Board “is a pure issue of government control,” Burdick said. “If the rules are handed down by the government, that’s government control. I’m saying the rules need to be handed down to doctors by doctors themselves.”

One thing the Health Security Board would not do is set prices. “This system is not going to be responsible for telling the country how much to pay a doctor,” Burdick said. “The country’s going to have to [figure that out] separately.” The board would discuss how healthcare would be funded and how many of what type of physician would be needed.

One of the most important cost issues is the price of drugs, Burdick said. “I think there is a general understanding that if we had a national system and a single wall for negotiation with drug companies, that their prices would have to come down. The converse question is, [does that] limit innovation, do we make it harder to get the drugs we need for patients, and I make the argument that the answer is No if we do it right.”

“The country could put together a process for negotiating a drug price that could be a lot lower while still recognizing the extraordinary value of all the pharmaceuticals to cure patients,” he added.

The system Burdick envisions would also have a role for state governments. “The process of arranging for payment but not for actual care decisions — logistics and certificates of need — the states would have a role as well.” That includes financing. “So the states would pay some and the federal government would pay some, and that income comes as a single ‘bolus’ payment to the physician and the hospital.”

The Canadian single-payer system is a good example of federal-state cooperation, he noted. “If you talk to Canadians they love their system, and they have a provincial system — the federal government pays [a certain amount] and the province pays the rest.”

Within the U.S., the way the organ transplantation system is structured is a great example of how things can work under a quasi-governmental organization — in this case, the United Network for Organ Sharing, an organization Burdick, as a retired transplant surgeon, is very familiar with. “It’s really a wonderful model for how the medical profession can make care decisions in this quasi-governmental, quasi-private structure I propose for the whole country. Nothing’s perfect…but it’s so much better than what we’ve got now.”

Joyce Frieden is news editor at Medpage Today.

http://www.medpagetoday.com/Washington-Watch/Reform/59127