During a recent conference about disparities in health care, physician and policy analyst Krisda Chaiyachati had compelling words for the audience.
"The challenge that sits in this room with us as heavily as it sits on my heart is this: Two people, equal in every way but race or ethnic heritage, walk out of a hospital having been treated for the same exact disease. But one experiences worse quality of care or has a worse outcome," he said. "Why is that? How can policy makers more effectively respond to the inequity we're all observing in the world and within the clinic walls around us?"
Chaiyachati, an assistant professor of medicine at the University of Pennsylvania’s Perelman School of Medicine, a clinical innovation manager at Penn Medicine's Center for Health Care Innovation, and a senior fellow at Penn’s Leonard Davis Institute of Health Economics, has long worked to understand and solve these disparities.
His work has included looking at how to improve accessibility to health care and how to overcome social barriers to care. We spoke to him recently about why racial disparities exist and what can be done about it.
The keynote speaker, Dr. Jonathan Woodson from Boston University, asked us to do some soul-searching to solve racial disparities. I was taking the message to heart. I shared a story I don’t often share. I grew up in a predominantly black community in Atlanta. My parents are both from Thailand. I was one of five individuals from my high school who were non-African American.
I mentioned this to highlight my upbringing in the shadows of the Civil Rights Movement and Dr. Martin Luther King Jr.’s legacy because it was the overarching narrative of Atlanta’s African American community. So, as a child, I was imprinted by the language of justice and equality. It was always part of the dialogue. College is when I started thinking, “What do I do about it?” I’ve spent much of my adult life trying to tackle that question.
Some classic studies have evaluated when a physician decides to treat or not. They show physicians a patient scenario – a patient with exact same diagnosis and same risk factors – but just change the color of the patient’s skin. We’ve seen that physicians will make different treatment decisions based solely on the color of the skin.
For example, with the opioid epidemic, the goal is to decrease the number of opiates. We’re seeing African Americans being taking off completely at a faster rate relative to white patients. We’re also seeing the flip side: fewer African Americans being started on medications to curb addictive cravings.
The other part of the racial disparity is a little more hidden and is often cast as what I’d call unintended consequences. We are really looking at that at Penn.
To set the stage, health care is starting to pay more attention to quality and value. How do we improve health care quality? How do we improve value for patients? So, the federal government has payment programs in place that penalize worse quality, but reward hospitals for improving care.
Great. But what we’ve seen is that racial disparities can worsen. It may be in part because trying to select people on the basis of whether they might or might not do well often happens to fall along lines of race. Or a hospital might be diverting resources toward one area and away from programs that support the needs of poor patients which often fall along the lines of race.
One of the big pushes of the Affordable Care Act was improving quality. This has remained constant. One of the first early measurements was if a hospital is doing well, patients should be able to go home and stay home. They should be at a low risk of being readmitted within 30 days of leaving the hospital. The federal government, through Medicare, targeted pneumonia, heart attacks, and heart failure. Hospitals that had high 30-day readmission rates were penalized.
That’s a laudable goal, but there’s a lot that happens after someone leaves the hospital. Some of it may be related to an inability to get medications. Maybe they need a ride for appointments. Maybe home is a bad situation.
Our paper showed that, in preparation for this penalty, hospitals took dramatic efforts to improve their readmission rates for the three main conditions. They wanted to be ready and likely thought about ways to improve care after patients’ hospital stays. These intense efforts narrowed the disparities.
However, when we looked at the other reasons people would have been admitted to the hospital – anything from infections to kidney problems to strokes – racial disparities have widened particularly in hospitals that care for minorities. Payment penalties placed such a spotlight on pneumonia, heart attacks and strokes, that hospitals had to shift resources away from these other conditions. As a result, we started seeing disparities widen.
The vast majority of my work is examining hospitals’ incentives and abilities to address social problems.
Transportation is an interesting one. Early last year, we published a study where we randomized 800 patients from West Philadelphia neighborhoods to get free Lyft rides, looking at whether they were able to make it to doctors’ appointments.
Surprisingly, we found that it made no difference whether we offered a free ride or not. We interviewed patients during and after this time to find out why. The story isn’t just about transportation. It’s a lot about life instability. “My child got sick.” “I just couldn’t take another day off of work.” “I just had to make priorities.” The second part of that story also has to do with what people perceive as the importance of an appointment. If I’m coming to an appointment just to have my medication tweaked, maybe I could put it off. It’s a logical thought process.
Interestingly, we’re starting to look at the data among cancer patients. Among Medicaid patients in West Philadelphia, we estimate that 15 percent are missing treatments. The number may not seem high, but the gravity of the situation is. So, we’re investigating what makes them miss their appointments. And what would it take to help people get a life-saving treatment? We are at the beginning of that work.
We need to better understand the interplay between social needs and better health outcomes. We know there are differences in outcomes between blacks and whites, poor people and rich people. The challenge remains: What can we do about it? And, if we do something about it, will it produce what we want, such as better health outcomes or better value?
The other thing is an ethical challenge. It becomes uncomfortable when we talk about it along the lines of race. We are more comfortable discussing poverty or income disparities. But we’re finding that when you deal with social needs, you help populations that are socially disadvantaged, and that has historically fallen along the lines of race.
For me, I’m just searching for equality. The thing I would want at the end of the day is that anyone can be admitted to a hospital, get the same treatment, and the same outcome, regardless of race or class or wealth. The only thing that should be limiting your ability to be healthier should be the science – where we are in finding cures and treatments. I’m learning that in health care we want to believe it’s the next new discovery that will save lives, but in reality, patients’ social circumstances play as a much, if not more, of a role.