BOSTON, MA – The Lown Institute, a healthcare think tank, has released the seventh edition of its Shkreli Awards, given each year to perpetrators of the most egregious examples of profiteering and dysfunction in healthcare. The “winners” are chosen with the help of a panel of judges made up of health policy experts, clinicians, journalists, and patient advocates. The awards are named for the infamous “pharma bro” Martin Shkreli, known for obtaining the manufacturing rights of the antiparasitic drug Daraprim and marking up its price by over 5,000 percent.

“When you see all these stories in one place, they stop being anecdotes and start to tell a bigger story,” said Vikas Saini, MD, president of the Lown Institute. “The need for more fairness and integrity in U.S. healthcare couldn’t be clearer.”

2023 Lown Institute Shkreli Award Winners

1. Columbia fails to stop OB-GYN from sexually assaulting patients despite years of complaints
2. Commonspirit nonprofit system pays CEO $35.5 million salary
3. Pharma claims Medicare drug price negotiation violates their constitutional rights 
4. Hospitals partner with private equity to offer medical credit cards
5. Vascular doctor allowed to keep practicing despite discipline in a dozen states 
6. GSK markets Zantac for decades despite potential carcinogenic compound 
7. Any narrowed artery seems a fair target for this alleged coronary stent king
8. Hospitals allegedly “dump” sick, homeless patients on the street
9. Physician payments help medical device maker test experimental products on poor, patients of color
10. Hospital threatens to ship expensive, comatose patient out of the country

A complete list of winners with descriptions, sources, and judges’ comments is available at the Lown Institute website.

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Join Lown Institute president Dr. Vikas Saini and guest panelists, award-winning author Harriet Washington and professor and activist Dr. Victor Montori, on Tuesday, January 9 at 1 p.m. ET for a countdown and discussion of this year’s winners.

About the Lown Institute

​​The Lown Institute is an independent think tank advocating bold ideas for a just and caring system for health. We envision a healthcare system focused on what’s best for people, like hospitals caring for those most in need, patients living without fear of financial distress, and health professionals finding joy in their roles. The Lown Hospitals Index, a signature project of the Institute, is the first ranking to assess the social responsibility of U.S. hospitals by applying measures never used before like racial inclusivity, avoidance of overuse, and pay equity.

Contact

Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org

The post PRESS RELEASE: Biggest healthcare fails of 2023 named in 7th annual Shkreli Awards appeared first on Lown Institute.

It turns out that inconsistencies around patient death status in the EHR is a pretty common occurrence. A recent report in JAMA Internal Medicine investigated the prevalence of outdated EHR information using records from seriously ill patients at UCLA Health. From the 12,000 patients identified in this category, 676 were marked alive in their health records but were actually dead in state public records.

It gets worse.

As these patients were still assumed to be alive, 541 of them still had appointments scheduled after their death. These patients continued to be contacted by health care staff and received approximately 221 calls and 338 portal messages unrelated to their deceased status. Additional contact attempts urged these patients to get preventative care like flu shots and cancer screenings, and medications were still being authorized for at least 88 dead patients. 

This mistaken follow-up is not only wasteful for the health system, it could be upsetting for family members to receive these messages. Inconsistencies in EHR data could also be perpetuated in AI algorithms trained on this data, which would make these tools less accurate. 

Drivers of EHR inconsistencies

A part of the problem lies in the fragmented nature of EHRs. The average health system uses 18 different EHR vendors across affiliated providers. But these EHR systems aren’t always able to talk to one another, meaning patients may still struggle to access their data, doctors may order duplicate testing, or need to transfer health data with fax or a CD. With so many data sources trying to provide a total view of the patient, it is easy to see why a patient may be marked as deceased in an EHR used for inpatient services but their specialist or primary care doctor may have no idea. And the fact that many EHRs cannot link up easily with federal and state records makes recording patient deaths a much harder task.

Even without interoperability issues, verifying patient death is not easy. Health systems have to access state records to confirm patient death, and ease in state accessibility varies. Even if the patient is found in state records, if they have a common name, there may not be enough information for health systems to verify that it’s the right person. Research services have to be contracted out to do a deeper search, but if the patient can not be linked to a social security number, or the information in their EHR is insufficient, a deceased status can not be officially confirmed. Internal departments often do not have an organized system or incentive to verify a flag in a patient’s chart indicating their death. 

Dr. Eric Cheng, chief medical informatics officer at UCLA, explained challenges with coordinating this information, in an interview with StatNews: 

“If a patient were to call the clinic or a doctor and say a family member died, we don’t necessarily do the best job in documenting that the same way. Physicians don’t know whether that’s stored, the front desk clinic may not be comfortable if they’ve never heard of the patient — they would all document in the note, but not in the official place where it should be.”

Dr. Eric Cheng, chief medical informatics officer at UCLA, in StatNews

How can EHRs be improved?

Creating requirements and standards for interoperability has been a goal for CMS for many years—and now it appears real change is finally on its way. CMS launched the Trusted Exchange Framework and Common Agreement (TEFCA) in December 2023, providing much-needed standards and allowing public-private collaboration to address gaps in health information exchange across EHR systems. Five organizations known as Qualified Health Information Networks (QHINs) are officially signed on to use this framework and can start exchanging data immediately. Hopefully, many others will follow. 

Patient misidentification not only contributes to poor tracking of death records but can also cause trauma and delayed care. To prevent this, another potential solution is creating unique patient identification numbers, a policy supported by some specialty groups, health systems, and industry organizations. 

A large part of making hospitals more accountable starts with having an efficient EHR system that keeps patient values as the focus. As solutions are being pushed, we hope to see advantages also impact entire health systems by preventing physician burnout, reducing administration costs, and providing high quality care.

The post When health records don’t capture patient deaths appeared first on Lown Institute.

#1 Review financial assistance and collection policies

Does your hospital allow patients to be sued for medical debt? What about denying nonemergency care for patients with outstanding debt? Knowing your hospital’s financial assistance and collection policies can go a long way toward improving social responsibility.

All nonprofit hospitals are required to have a policy around financial assistance outlining who is eligible for free and discounted care and how they can get it. Most also have a collections policy that shows what “extraordinary collection actions” the hospital is allowed to take if patients don’t pay (like garnishing wages, suing patients, or sending debt to collections).

However, the extent to which hospitals provide free and discounted care varies widely across the country. In most states, there aren’t strict rules about who should be eligible for assistance, so it’s up to hospitals to create their own policy. Hospitals also differ in the collections actions their policy allows them to take, with some allowing for legal action, reporting debt to collection agencies, and denying nonemergency care for patients with debt.

For hospitals looking to boost their financial assistance ranking on the Lown Hospitals Index, there may be room for improvement in their policies. Hospitals should examine their policies with the following questions in mind:

• Are the eligibility requirements broad and generous?
• Are patients being adequately screened for eligibility?
• Is the application short and easy to understand?
• Are there additional asset tests or residency requirements?
• Are aggressive collection actions allowed?

Reviewing these policies can help hospitals understand where they could expand eligibility or streamline the process to get aid to more needy patients.

#2 Invest in the social drivers that affect upstream health 

Clinicians know that most of what determines their patients’ health happens before patients even step foot in the hospital. Things like environment, education, neighborhood safety, housing, and nutrition make up the social drivers of health. Hospitals and healthcare systems can make a huge impact on community health by investing in these factors, even if they’re outside the hospital walls.

Some hospitals have been incredibly innovative in their programming around social drivers of health, including:

• Helping patients pay their utility bills
• Offering free food from food pantries 
• Investing in affordable housing
• Supporting the local economy through local contracting and hiring

On the Lown Index, we measure hospital spending on community investments like these. (See which hospitals are already at the top in your state!)

#3 Become champions for high-value care 

Overuse of medical services with no or little clinical benefit is unfortunately prevalent at U.S. hospitals. A recent report from the Lown Index found that hospitals delivered nearly 230,000 unnecessary coronary stents to Medicare patients from 2019-2021.

There are many things that hospitals can do to protect their patients from exposure to harm and unnecessary cost. For example, when Children’s Hospital of Colorado found out they had a very high rate of CT scan for abdominal pain (which is not recommended by pediatric specialty organizations), they created a plan of action. They implemented a new protocol to get surgeon consultation in the ER before a CT scan is ordered, to decide whether or not patients were at high risk of appendicitis. Within two years, the hospital cut its rate of these CT scans from 45% to 10%.

Hospitals will soon be able to evaluate their CT radiation dose compared to their peers, using CMS’ new metric on radiation quality. For hospitals that are using too high of a dose, they can undertake initiatives to educate clinicians about reducing their dose to avoid exposing patients to unnecessary harm. 

#4 Evaluate new AI tools with an eye toward equity and overuse

Artificial intelligence (AI) tools are taking off in health care, and hospitals are no exception. AI tools have the potential to improve patient outcomes, reduce administrative burden, and even improve health equity. For example, a recent study found that a new AI algorithm has the potential to identify knee pain in Black patients with osteoarthritis more accurate than radiologists. 

However, experts are also sounding the call about the potential for AI tools to exacerbate existing patterns of racial inequity and overuse in health care. For example, a study of AI diagnostic algorithms for chest radiography found that underserved populations (which are less represented in the data used to train the AI) were less likely to be diagnosed using the AI tool. And a Lancet study testing AI breast cancer screening found that AI-supported screening detected nearly double the number of (DCIS) low-grade cases than standard screening. 

Given these concerns, hospitals should take steps to ensure that their implementation of AI tools is socially responsible. Here’s how some hospitals are already doing this:

• NorthShore – Edward-Elmhurst Health and AVIA are working together to develop a generative AI plan for healthcare systems that focuses on the risks and opportunities of AI as well as guidelines to monitor their usage and effects.
• Hospital systems like CommonSpirit and Penn Medicine are collaborating with health systems and other organizations to screen for, identify, and eliminate biases within EHRs. 
• Houston Methodist Hospital created iBRISK, a breast cancer risk assessment tool supported by AI. iBRISK takes into account patients’ demographics and medical history before recommending future diagnostic testing. By targeting screening toward patients with the highest risk, we improve the chance of benefit from screening.

#5 Prioritize equitable pay for employees 

It’s no secret that a happy, healthy staff makes for better patient care. Improving employee satisfaction is easier said than done, but ensuring equitable pay for all employees is a good start. 

Compared to other nonprofits, hospitals are outliers in terms of how much they pay their CEOs. Lown Index data on pay equity found that nonprofit hospital CEOs are paid eight times the rate of hospital workers without advanced medical degrees, on average. Creating incentives for CEO pay based not only on financial performance but patient outcomes, community investment, and other social responsibility metrics, would help align incentives for leadership with those of the community.

Committing to providing a living wage for all hospital workers would be an incredible boost for financial security within the community. The median wage for health care support, service, and direct care jobs was $13.48 an hour in 2019. California took a giant step by raising the minimum wage for healthcare workers to $25 an hour. Because hospitals are often one of the largest employers in a region, raising the minimum wage helps to support local economic development, and could even improve community health. 

We’re envisioning a 2024 full of innovation and collaboration in the hospital space, and these socially responsible hospitals give us hope that this vision will become a reality. We hope you will join us next year as we continue to build the movement for socially responsible healthcare.

The post Five ways hospitals can be more socially responsible in 2024 appeared first on Lown Institute.

Given that most Americans cannot afford an unexpected $500 bill without going into debt, having financial assistance available and easily accessible is key for reducing the burden of medical debt in the U.S.

Check out our community benefit policy tracker to see the latest on how states are tackling hospital accountability on this issue!

Trends in financial assistance spending

Unfortunately, several recent reports show that spending on financial assistance (also known as “charity care”) appears to be declining among hospitals overall. A Modern Healthcare analysis found that hospitals’ median financial assistance spending as a percentage of operating expenses declined from 1.21% to 0.99% from 2020 to 2022. Although one might have expected financial assistance spending to increase due to the great need for emergency care during Covid-19, hospitals’ expenses also increased greatly from labor and other costs. 

Another 2023 study in Health Affairs found that on average, nonprofit hospital income grew from 2012-2019, but financial assistance declined slightly; in comparison, for-profit hospital spending on financial assistance more than doubled during that time.  

Hospitals also differ widely in the amount of free and discounted care they provide. For example, health systems like NYC Health+Hospitals devoted 6.85% of their expenses to financial assistance in 2022, while Baystate Health in Massachusetts spent only 0.16%, according to Modern Healthcare.

I’d like a refund, please

In Washington state, where there are additional state requirements for nonprofit hospitals, the Attorney General has been investigating certain health systems for inappropriately billing patients who should have qualified for free care. Recently, PeaceHealth System agreed to pay $13.4 million in refunds to thousands of patients who should have were eligible for free or discounted care but were billed anyway. This includes $4.2 million in direct refunds for more than 4,500 patients and up to $9.2 million in refunds for approximately 11,000 additional patients if they validate their income for eligibility. 

Requiring hospitals to refund patients who were billed erroneously is a growing trend. In Oregon, recent legislation requires hospitals to refund patients who paid for care when they were eligible for assistance. And Maryland is refunding patients who were billed for hospitals services from 2017-2021 when they could have qualified for free care.

Hospital sued patients who should have gotten free care

Some hospitals go beyond billing patients, bringing lawsuits to those unable to pay. Louisville Public Media recently reported that Norton Healthcare filed thousands of lawsuits for unpaid medical bills, despite many of those patients qualifying for free or discounted care. In many cases, patients are unaware they may be eligible for free care, or they face administrative barriers to assistance. 

Despite the established regulations around community investment and charity care, the lack of enforcement has resulted in crippling medical debt for thousands of Americans. Let’s hope the recent pressure policymakers and media are putting on hospitals will be encourage them to give more free care, in pursuit of their social mission. 

The post Policymakers and media put pressure on hospitals to give more free care appeared first on Lown Institute.

Bringing together Dr. Vikas Saini (the Lown Institute), Dr. Katherine Peeler (Boston Children’s Hospital), Dr. Omar Lateef (RUSH University Medical Center), and Dr. Thea James (Boston Medical Center), the discussion focused on the role of hospitals in addressing problems like moral stress and burnout and how a commitment to equity fits into their resolution. Watch the video of the event and read some of the highlights from the discussion.

The dilemmas facing hospitals 

Panelists emphasized the conflicting incentives for health systems between prioritizing equity and keeping the lights on. “The more right you do in health care, the more wrong your operating margin will report at the end of the year,” said Dr. Lateef. 

He shared how RUSH University Medical Center’s strategy during COVID-19 of taking as many patients from safety net hospitals as possible was an energizing force for physicians who saw the difference they were making in their community, but it created financial issues for the hospital. “Because we had lost so much money, we were going to fall below our debt covenant. We couldn’t pay our loans …. We had unprecedented losses through the pandemic,” he said.

Another key challenge for hospitals is making sure that the C-suite and frontline hospital staff are on the same page. “Hospitals often say they have a plan, but physicians who are in the trenches often don’t see this plan,” Dr. Peeler explained. “If hospital’s systems that support equity… aren’t clearly communicated, physicians find themselves in the tough position of not knowing how to actually access the resources in their own hospital to deliver the care their patients deserve,” she said.

And for hospital workers who had been trying to call attention to structural racism for years, it seemed suspect that leaders were vowing to improve equity only after it became popular to do so. “I couldn’t understand that while people don’t recognize inequity when it’s clearly in plain sight all day long, how can all of the sudden people have this commitment to equity?” said Dr. James.

How equity metrics help hospitals “do the right thing”

In order to bolster the contents and actionability of hospitals’ health equity plans, hospitals have to measure what matters and do so in a transparent way. “If we’re going to reframe what it means to be a great hospital, we need new metrics,” said Lown Institute President Dr. Saini. This goal is what drove the creation of the Lown Institute Hospitals Index for Social Responsibility, which evaluates hospitals on equity and value as well as outcomes. 

“Let’s measure things that aren’t currently being measured. Let’s do it in a way that’s transparent, and let’s measure things that would be really hard to game.”

Dr. Vikas Saini

However, it’s not just enough to measure health disparities or community investment – institutions have to be willing to internalize and act upon these results, said Dr. Lateef. That can be tough when the results bring feelings of discomfort and frustration for hospital systems. “We all feel like we’re doing an incredible amount of work and no one wants to hear that they’re not doing enough,” he said.

Equity-related measures in particular can provide a critical opportunity to increase the efficiency and impact of hospitals’ plans in the long-term, but only if hospital leaders take them to heart. “Metrics that look at equity should be discussed in boardrooms and when you’re doing that … you’ll drive change, said Dr. Lateef.

For Dr. James at BMC, to make strides on equity it was important to “look inside our own house,” she said. Their “Health Equity Accelerator” program started with hospital leaders meeting monthly in working groups to identify the biggest health disparities in their own patient population. Using this model, BMC has been able to reframe their approach to medicine by putting the identification and resolution of the root causes of ill-health at the forefront of their operations.

It’s not easy to remove health inequities that are baked into the system, but having health systems, researchers, and policymakers working together is a start. “In the same way that multiple forces led us to this moment over many decades, multiple economic, social, and political forces are going to be necessary to get us out of it and that means multiple solutions, different initiatives, multiple domains – all working together if we’re going to pull ourselves out of this tailspin,” said Dr. Vikas Saini.

The post WATCH: Hospitals reveal key challenges to achieving equity, and how they’re overcoming them appeared first on Lown Institute.

The nation is facing a significant shortage of physicians, particularly in rural areas. In fact, the shortage is estimated by the American Medical Association to fall between 37,800 and 124,000 physicians within the next 12 years. From primary care to psychiatry, obstetrics, neurology, and oncology, numerous specialties are facing a physician shortage. And with more and more physicians retiring and quitting from burnout, the problem isn’t getting better.

Rural areas face the brunt of this shortage as urban areas have higher densities of both primary care physicians and specialists. Patients in rural areas tend to be older, poorer, and sicker, especially with chronic conditions. With fewer doctors around, they have to travel further for both preventative and emergency care, putting them at greater risk for poor health outcomes and mortality.   

The mismatch between medical school enrollment, residency slots, and the need for physicians in the workforce has resulted in a lose-lose situation where perfectly competent physicians face barriers to working while simultaneously, entire regions of the country are without sufficient access to physicians.

What can we do about this mismatch and resulting dilemma?

Increase residency opportunities through both federal and state funding

Most residency slots are funded by the Centers for Medicare & Medicaid Services (CMS), meaning that they need action by the federal government for expansion. This also means that no significant action had been taken for over 20 years (Congress had actually capped the number of residents), until the COVID-19 relief bill was passed. The COVID-19 relief bill opened the door for 1,000 new residency slots, 10% of which must be in rural areas. Another similar bill has been introduced in Congress that would allocate funding for an additional 2,000 residency slots every year for 7 years starting in 2025.

Another option is to increase residency slot funding on the state level. The majority of doctors stay in the states where they completed their residency. Both California and Texas–where the shortage is predicted to be the worst–approved multimillion dollar expansions in funding, resulting in increase retention of physicians in underserved, local areas. 

The Assistant Physician model

Missouri took a different approach, passing a law that launched a new category of licensure called assistant physicians (not to be confused with physician assistants). This allows medical school graduates who didn’t match to a residency on their first try to practice primary care in rural and underserved areas under the supervision of a licensed physician. While the program is relatively new, there is evidence it’s working at alleviating the rural physician shortage. As of early 2023, there were nearly 300 assistant physicians licensed in the state, about 3% the number of primary care doctors. Six other states now have similar laws allowing for unmatched medical school graduates to practice while they continue trying to match with a residency. Washington specifically designed their program for international medical graduates. 

The physician shortage in rural areas is a complex problem with numerous potential solutions. We need to increase the number of licensed medical professionals–including nurse practitioners, physician assistants, and international medical graduates–as well as retaining them. We need to reduce burnout so clinicians don’t hate their jobs and retire early. We need to incentivize trainees to serve in medical deserts where they’re needed the most. 

The realignment of community needs and the physician workforce pipeline will be tricky, but not impossible. While telehealth may help in the coming years, we should still be considering the most efficient way to build up our healthcare practitioner workforce.

The post How can we fix physician shortages in rural America? appeared first on Lown Institute.

Last month signified a victory for high-value care with the approval of a new patient safety metric, Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults. Starting in 2025, the measure will be integrated into the Centers for Medicare and Medicaid Services (CMS)’s Merit-based Incentive Payment System (MIPS) and Hospital Inpatient and Outpatient Quality Reporting Programs, with the goal of regulating patients’ exposure to radiation during computed tomography (CT) scans. 

This new measure of radiation quality sheds light on an important potential harm of imaging overuse. Here’s what it means for the future of provider accountability and patient safety.

Radiation exposure during CT scans

Each year, it is estimated that more than 80 million CT scans are performed in the United States. The computerized x-ray imaging procedure has the power to inform diagnostic decisions for everything from tumors and lesions to heart disease and pneumonia. 

While CT scans are an essential diagnostic tool in doctors’ medical toolkits, it’s important they be used carefully. Each time a CT scan is performed, the patient is exposed to ionizing radiation, which is required to produce an internal image for the physician to review and make diagnostic and treatment-related decisions. However, in large doses, exposure to such radiation can damage genetic and cellular material, increasing the risk for mutations and consequently, cancer. 

“Many patients still routinely receive radiation doses two or three times what they should. That will lead to cancer in a small percentage of patients, approximately thirty-six thousand cancers every year. This means that CT causes two percent of annual cancers, and we can reduce that risk substantially without reducing the value of the scans.”

Dr. Rebecca Smith-Bindman, UCSF

Given how common CT scans are and the potential risks of radiation exposure, it seems obvious that there would be standard measures for how much radiation doctors can use. But in fact, the amount of radiation that a patient gets in a CT scan varies widely, largely due to differences in the ways in which physicians use CT machines across institutions. The results of studies exploring the implications of this are alarming, with one citing a 13-fold mean variation between the lowest and highest dosages used across different CT scans. 

Measuring what matters in imaging

To tackle the widespread variation and lack of regulation surrounding CT radiation dosage, UCSF Professor in Residence Dr. Rebecca Smith-Bindman and her team developed a new measure, Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults. The measure sets lower and upper thresholds for radiation dose based on patient characteristics and type of CT scan. The radiation dose floor ensures that enough radiation is used to create an image of acceptable quality, while the ceiling prevents over-radiation that could increase cancer risk. 

Here’s an example from researchers at UCSF:

The measure is implemented through software that links to providers’ electronic health records, so clinicians can get real-time feedback on their performance. CMS will evaluate providers based on “the percentage of CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality.”

The future of overuse metrics

The new radiation quality metric is a great example of how overuse measures can help improve quality and reduce patient harm. CMS estimates this measure could prevent nearly 14,000 cancers among Medicare beneficiaries and save as much as $5 billion to Medicare each year.

This overuse metric is one of many that deserve broader use among providers. Through our research on the Lown Hospitals Index, we’ve seen how common unnecessary imaging and procedures can be in U.S. hospitals. For example, a Lown Institute report from October 2023 found that US hospitals delivered nearly 230,000 unnecessary coronary stents from 2019-2021– that’s a rate of one every seven minutes. The Lown Hospitals Index for Social Responsibility evaluates hospitals on 11 other low-value services, including unnecessary imaging like CT scans for fainting and procedures like spinal fusion for lower back pain. We look forward to incorporating the new metric of CT radiation quality into the Index as data becomes available. 

The post A win for high-value care: CMS approves new measure of CT radiation quality appeared first on Lown Institute.

Low-value care and equity

Given the health risks of overuse, it’s important to understand the impact of low-value care on health equity. Are people of color at higher risk of overuse than white patients, or vice versa? The evidence on this so far is mixed. A systematic review of studies looking at low-value care by race found that white patients were more likely to receive unnecessary care, but another more recent study found higher rates of overuse for certain low-value services in Black and Hispanic patients, such as feeding tubes for dementia. Clearly, there is a lot more to be studied on this issue.

Cue a new analysis from Harvard Medical School professor Dr. Ishani Ganguli and colleagues in The BMJ. This study looked at rates of 40 low-value services in nearly 10 million Medicare patients across 595 health systems. Ganguli and colleagues compared the likelihood of receiving low-value care between Black and white Medicare patients, including a comparison of patients within the same health system. Low-value services measured included screening tests, diagnostic tests, monitoring tests, drugs, and procedures.

Here are key takeaways from their study:

• There were significantly different rates of low-value care for 29 of the 40 services measured, although most of the differences were small. Black patients had higher rates of nine low value services and white patients had higher rates of 20 low-value services. 
• White Medicare patients were more likely to receive low-value screening tests such as prostate-specific antigen testing in men over 75 (31% v 26%) and cardiac screening (5% v 2%), as well as treatments such as antibiotics for cold or ear infection (37% v 33%), and vertebroplasty (5% v 3%) which is an injection of cement into the backbone.
• Black Medicare patients were more likely to receive feeding tubes for advanced dementia (9% v 2%), two or more concurrent antipsychotic medications (8% v 5%), and certain low-value acute diagnostic tests, like imaging for uncomplicated headache (7% v 3%).
• Differences in low-value care remained even when comparing patients within the same health system. That’s important, because it indicates differences in the way patients of different races are treated by the same providers–rather than just differences in culture between the health providers they frequent. 

Drivers of disparities in low-value care

What could explain these differences? The study authors suggest some potential reasons why Black patients could be more likely to receive low-value diagnostic tests:

“Mistrust in the healthcare system because of historical and present day racism might contribute to Black adults being more receptive to diagnostic testing when acutely ill—in this scenario, it is possible that a tangible test is more reassuring than a clinician’s words and might serve to lessen valid concerns about undertreatment.”

The authors also point out that structural barriers to care for Black patients can make it hard to access care earlier and result in them arriving to the ER sicker, which could prompt low-value testing. Additionally, if patients are more likely to seek care in the ER or urgent care as opposed to primary care, they may be subject to more low-value testing from doctors who don’t know them well. Why does this matter? Low-value diagnostic testing exposes patients to radiation exposure, out-of-pocket spending, and additional follow-up testing and procedures (known as “care cascades”).

Black patients were also more likely to receive feeding tubes in the setting of advanced dementia, a practice that does not help patients live longer, and is not recommended for these patients. Differences in rates of feeding tube usage may reflect lack of trust and communication between clinicians and patients; one study found that 14% of family members of patients with feeding tubes reported that there was no discussion about feeding tube insertion, and 42% reported a discussion that was shorter than 15 minutes.  

On the flip side, why are white patients more likely to receive certain low-value screenings and treatments? The authors suggest that white patients could be more likely to request these services, or clinicians might be more likely to offer them, perhaps because of implicit biases. Black patients are less likely than white patients to receive certain cancer screenings that are considered high-value, such as age-appropriate colonoscopies and mammograms, so it makes sense that they are also less likely to receive low-value ones. 

This study provides valuable information on the intersections between health equity and value, but there’s still much more to learn. The authors suggest that health systems measure use of low-value services stratified by racial group and sex, to identify potential disparities. “These results invite further exploration of differential access by race to routine, high value primary care, patient-clinician concordance, and trust,” they write.

The post Study finds racial disparities in low-value care, even within the same health systems appeared first on Lown Institute.

I was introduced to the world of public health in high school by a teacher who was ahead of his time. While most people first learn about epidemiology in college, I was lucky enough to attend one of the first epidemiology classes to ever be held in a public high school, led by the brilliant Evern Williams.  Learning about public health at a younger age was groundbreaking because it made me see the problems in my surrounding community through a different lens.

Babies having babies

Teen pregnancy was one example. I was aware of classmates who were dropping out of school due to pregnancy, but what hit me hardest was seeing a pregnant student walking out of a middle school my younger sister attended. I froze in shock realizing that her peer could be no older than 13. My mom used to call this “babies having babies.”

With new understanding that the unusual number of teen pregnancies in my community was actually a public health concern, my curiosity and determination were ignited. I began researching incidence rates of teen pregnancy in my community and reasons why this could be a pattern. I recognized that in my county there were gaps in health education, self-efficacy, and tools for upward mobility. So, I began a public health intervention called C.H.A.R.M. which stood for Conscious of Health, Attitude, Reality, and Manner.

This program was designed for girls at my former middle school, and the initiatives included emboldening their voice through public speaking and situational awareness activities. They were provided women’s health education to empower them to make informed decisions on taking care of their own bodies and advocate for their health needs. The girls were also given career talks and help with goal planning in order to provide clear direction with purpose, and motivation to identify distractions that could lead them astray.

Nearly ignored to death

Soon after, I had the privilege of being in the first public health program at the University of Miami. The horrors of poor healthcare delivery, preventable deaths, and barriers for under resourced groups were unveiled to me. Dealing with my own health battle during this time, I experienced fragmented care coordination, high medical costs, and poor quality care up close and personal. In one case, complications from a surgery for a kidney stent placement almost cost my life. When I sought help from my urologist upon feeling sick, my symptoms of pain and nausea were deemed unrelated to the recent procedure she performed. However, my condition quickly worsened and I had no choice but to head to the emergency room.

“Your wait to be seen will be at least six hours.”

Desperate for help, I explained to the triage nurse that I was surely experiencing kidney complications. My heart sank when she replied,“Your wait to be seen will be at least six hours.” I had no idea how I was going to endure such a long wait time, and I was confounded to see patients going ahead of me that seemed far less acute. When I was finally seen by a doctor, it was determined that I had sepsis and my kidney was enlarged from the clogged stent. I was immediately rushed to emergency surgery and would spend another week recovering in the hospital.

I recognized that I now had an inextinguishable determination to hold health care systems accountable for delivering poor quality care. I also wondered,”What could I do to prevent the crises of chronic disease and poor health outcomes, in the same way I had helped my younger peers in high school? How can we make health care low cost and accessible for all?”

The Lown Institute also shares this tireless mission to reform health care. Through innovative research, they uncover problems and highlight solutions to build a high-quality, accessible, and equitable health care system that addresses whole person care. I am excited to be a part of the Lown family and start work on two major projects I am tasked with: predatory billing practices and deficits in community benefit spending for hospitals. I believe that addressing issues like these can lower barriers to health care, reduce health disparities, and ensure access to vulnerable populations who deserve high-quality care.

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Dr. Saini on the decision to measure stent overuse:

“The issue with stents illustrates some of the deep problems in American medicine, which has to do with how do you decide when something works and when it doesn’t? How do you decide if it works, how much to pay for it? When something is discovered not to work and you’re already paying for it, how do you turn that down? These are all difficult questions, and they’re not new.”

Dr. Saini on treating healthcare like a market:

“I don’t want to walk into my doctor’s office thinking I’m at a McDonald’s. I want to be listened to. I want to be known. I want my background, my family to be known. I want the clinician to hear me and to give me advice. And I want the dollars and cents in the background.”

Dr. Saini on the feasibility of transformative healthcare change:

“If people had an opportunity to work together, crowdsourcing the design of the health care system they want for themselves, their families, and others, I think it’s doable. It’s a big project. But when did we stop trying big projects? Moonshots are what we should try to do, and this is one of the biggest moonshots there is really: fixing American health care.”

Dr. Saini on what a uniquely American healthcare system could look like:

My own view is that we can do a lot better than Medicare or Medicare For All. We can do better in a way that would be different from Canada, different from Europe, different from any other country. If very American, it would be decentralized. It would have a lot of local and regional autonomy and control. It would have elements that were tuned to the local culture…America could have the best health care system in the world.

The post LISTEN: The “biggest moonshot” is fixing American healthcare appeared first on Lown Institute.