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P E R S P E C T I V E :
D I S P A R I T I E S
6 December 2005
Investment, Innovation,
And Disparities:
A Complex Relationship
At the moment, the United States is left with a bottom-up
approach to equity in its health care system.
by Timothy G. Ferris and David Blumenthal
ABSTRACT:
Robert Hurley and colleagues find growing disparities in health care. Their methods are rigorous, but key-informant interviews have limitations. Part of their argument rests on observations regarding the diffusion of technological and administrative innovations. The development of disparities will depend on how quickly innovations diffuse to underserved populations. While we look for other supporting data, decreasing public coverage for the poor, medications, and mental health services sends a clear signal from emergency departments. Human suffering reinforces the need to redouble our efforts to patch up coverage holes during good times and keep coverage from unraveling during lean times.
The paper by Robert Hurley and colleagues paints an alarming but not unexpected picture in their assessment of the most recent data from the Community Tracking Study (CTS).1 The study’s systematic, highly structured interviews recorded the widespread impression among key informants in multiple U.S. cities that disparities in health care delivery, particularly those related to access to technology and innovative services, are growing. The findings are alarming because of their potential implications for widening the well-documented gaps in health care between the well-served and the underserved. At the same time, the results of this latest CTS round might have been expected because of state budget crises and reduced federal support for health care programs designed for low-income populations.
The paper by Hurley and colleagues raises at least three questions. The first is whether things are truly as bad as the paper portrays them to be. After all, this work was based on qualitative case studies rather than the quantitative survey results or claims data analyses normally cited to support conclusions about problems with access to care. The second question is whether the paper tells us anything we didn’t already know: Are they different, or do they constitute just another grim reminder of the way our health care system fails our vulnerable citizens? And a third question is whether this study suggests changes in how we should approach the problem of our two-class care system. We briefly approach each of these questions below.
Although the published paper contains little detail on the CTS’s methods, these have been described more thoroughly elsewhere.2 The CTS includes a highly formalized and rigorous data collection process that arguably meets the highest standards for qualitative data collection. Importantly, the CTS samples key informants, clinicians, and managers, who have firsthand experience with the particular issues being put to them for consideration. In addition, the interviews are structured so as not to lead the informant down any particular path. After data are collected, analyzing qualitative data poses additional challenges. How are thousands of interviews analyzed in an unbiased manner to create the picture provided by Hurley and colleagues? In the context of the this paper, we receive little information as to how the issues of technology and disparities were assessed. There may be some increased risk at this stage in the process for falling prey to identifying exactly what they were looking for, thereby creating a self-fulfilling prophecy. But viewed in the context of the growing ranks of uninsured Americans and the previously well-documented access problems associated with uninsurance, we would have been more surprised if they had not found increased problems for providers of care to the uninsured. Based on these considerations, we find their results believable.
New information? So is there new information here? This question is more difficult to answer and rests on the interplay of the diffusion of innovation and the effectiveness of those innovations. Hurley and colleagues note that providers’ recent increase in investment in health care infrastructure has been greater for wealthy communities than for the less-well-off. Although the burst in investment might be new, the pattern they describe seems consistent with health care investment in past decades. As the work of Elliott Fisher and colleagues has shown us, having more boutique cancer and cardiac centers in wealthy suburbs does not necessarily mean better care or better outcomes.3 And the recent experience with Vioxx suggests that there could be some advantages to being a bit behind on the innovation adoption curve.4 By focusing so heavily on the availability of new, high-end, and often overused health care technologies, the Hurley team leaves open the question of whether the highly plausible disparities they have documented really matter for the health of affected populations. More worrisome would have been the detection of growing gaps in the use of evidence-based care—also plausible, but much more difficult to detect using the qualitative case study approach. Be that as it may, the authors’ juxtaposition of exploding investment in high-margin activities (which might have no net health benefit) with an increasing number of poor and mentally ill people going without services points out some of the more insidious incentives in our system.
Hurley and colleagues also make a series of observations regarding health insurance coverage. They note that innovations in coverage have not diffused into the Medicaid population. Again, this could be good or bad, depending on your perspective. Three innovations are playing out in the commercial insurance market: pay-for-performance, disease management, and consumer-driven health care. At this point it is difficult to state unequivocally that any of these is having a major impact on improving care.5 There also is mounting evidence of Medicaid involvement in at least the first two of these approaches.6 For example, Florida has led state Medicaid agencies in experimenting with disease management, and several other states have recently followed.7 Medicaid programs are also beginning to experiment with pay-for-performance. On the other hand, rapid adoption by Medicaid agencies of consumer-driven health care policies would be cause for considerable concern. Although some carefully executed and monitored financial incentives could prove useful in the Medicaid population, the low health literacy, limited financial reserves, and high prevalence of mental illness suggest that this population could not be readily turned into “informed and activated consumers” of health care. Again, with respect to administrative advances in insurance delivery, being on the leading edge of innovation adoption might not be a good thing. We might hope that the delay in diffusion of these innovations to Medicaid reported by Hurley and colleagues will result in adoption of only those aspects of these innovations that actually benefit patients.
What should we do differently? So what, if anything, should we do differently? Hurley and colleagues raise, if only by inference, the question of whether we should address disparities by keeping the lid on extravagant and excessive spending in suburban communities. This is the approach implied by the Dartmouth group’s focus on the role of “supply-sensitive” care in explaining variations between high- and low-cost health care markets. Ironically, this might not release resources for the uninsured and the poor, but might instead protect the health of suburban “beneficiaries” from these hot new service lines.
It is tempting to suggest that the dollars spent on new imaging centers in wealthy suburbs could be redirected to the poor through regulation or changing incentives. However, it is probably a nonstarter to attempt addressing disparities by withholding care, however unproductive, to the wealthy. In this sense, disparities might not be the issue at all. The issue is strengthening the safety net so that the holes torn by lean times described in Hurley and colleagues’ paper are smaller and easier to patch. At the moment, we are left with a bottom-up approach to equity in our health care system: taking every opportunity to invest in safety-net institutions; advocating for small and large improvements in Medicaid, the State Children’s Health Insurance Program (SCHIP), and high-risk pools; and cultivating the occasional opportunity for breakthrough, such as recent legislation to provide coverage to everyone in Massachusetts. Fundamentally, therefore, there is, regrettably, nothing dramatically new in the work by Hurley and his colleagues. It recalls us to our knitting.
NOTES
1. R.E. Hurley, H.H. Pham, and G. Claxton, “A Widening Rift in Health Care Access and Quality: Growing Evidence of Economic Disparities,” Health Affairs, 6 December 2005,
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.566.
2. For more background on CTS methodology, see Center for Studying Health System Change, “Site Visit Methodology,” 15 November 2005, http://www.hschange.org/index.cgi?data=17 (accessed 15 November 2005); and P.B. Ginsburg et al., “The Community Tracking Study Analyses of Market Change: Introduction,” Health Services Research 35, no. 1, Part 1 (2000): 7–16.
3. E.S. Fisher and H.G. Welch, “Avoiding the Unintended Consequences of Growth in Medical Care: How Might More Be Worse?” Journal of the American Medical Association 281, no. 5 (1999): 446–453; E.S. Fisher et al., “The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 138, no. 4 (2003): 288–298; E.S. Fisher, “Medical Care—Is More Always Better?” New England Journal of Medicine 349, no. 17 (2003): 1665–1667; and J.E. Wennberg, E.S. Fisher, and J.S. Skinner, ”Geography and the Debate over Medicare Reform,” Health Affairs, 13 February 2002,
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w2.96 (accessed 14 November 2005).
4. U.S. Food and Drug Administration, “Merck Withdraws Vioxx; FDA Issues Public Health Advisory,” November–December 2004, http://www.fda.gov/fdac/features/2004/604_vioxx.html (accessed 22 November 2005).
5. M. Rosenthal, C. Hsuan, and A. Milstein, “A Report Card on the Freshman Class of Consumer-Directed Health Plans,” Health Affairs 24, no. 6 (2005): 1592–1600; M.B. Rosenthal et al., “Early Experience with Pay-for-Performance: From Concept to Practice,” Journal of the American Medical Association 294, no. 14 (2005): 1788–1793; and Congressional Budget Office, An Analysis of the Literature on Disease Management Programs, 13 October 2004, http://www.cbo.gov/showdoc.cfm?index= 5909&sequence=0 (accessed 15 November 2005).
6. The Center for Health Care Strategies, http://www.chcs.org, collects and organizes information on quality improvement interventions in Medicaid populations.
7. C. White et al., “State Medicaid Disease Management: Lessons Learned from Florida,” March 2005, http://www.healthstrategies.net/research/docs/Duke_DM-Florida.pdf (accessed 15 November 2005).
Timothy Ferris (tferris{at}partners.org) is an assistant professor of medicine and of pediatrics at Harvard Medical School in Boston, Massachusetts. David Blumenthal is director of the Harvard University Program for Health Systems Improvement and the Samuel O. Thier Professor of Medicine and professor of health care at Harvard Medical School.
Read related articles
by Robert E. Hurley and colleagues , and Eric L. Book .
DOI: 10.1377/hlthaff.w5.580
©2005 Project HOPE–The People-to-People Health
Foundation, Inc.
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