Disparities in care still undercut quality progress
■ Increasing trust and building a "medical home" are proposed fixes to quality and disparity problems.
By Andis Robeznieks — Posted Jan. 19, 2004
Tony Hampton, MD, urges patients at Circle Family Care's clinic on Chicago's West Side to "be a statistical abnormality." He wants them to be in that minority of minority patients who stay on their medications, lose weight and quit smoking.
In fact, Dr. Hampton, a family physician, has made a special effort to reverse health care trends involving low-income and minority patients. He is trying to reduce their use of hospital emergency departments and increase delivery of preventive care.
These are just two issues documented in a pair of recently released government reports about the quality of and disparities in the nation's health care system.
The reports say quality health care is not universal and that differences exist along economic, racial, ethnic and geographic lines; that chances to provide preventive care are often missed; and that there is much to learn but progress is possible.
Some experts contend that the only way to address the deficiencies is to reform the health care system.
"These are symptoms that we have a system that doesn't work," said American Academy of Family Physicians President Michael Fleming, MD. "The answer is health system change, because I don't think there is an answer in the way the health system is currently configured."
The AAFP is working toward building a health care system using a primary care-based model. Dr. Fleming said such a system would reduce disparities by providing a "medical home" to people who now see a different physician each time they enter the health care system. "They receive episodic and urgent care rather than continual and coordinated care," said Dr. Fleming, of Shreveport, La.
Reducing variables in practice and aligning financial incentives toward providing better care is the solution prescribed by Gail M. Amundson, MD, associate medical director of quality improvement for Bloomington, Minn.-based HealthPartners, a group of nonprofit health care organizations providing care, insurance and HMO coverage to some 660,000 people. "Physicians are paid for seeing patients," she said. "Except for a very few examples, there is no payment for the outcomes of patient visits."
Health care is a cottage industry, Dr. Amundson said, with each "shop" deciding how it wants to operate. "The end result is a large amount of variability in care and significant gaps in the quality of that care."
One form of outcome-based incentives already exists, said AMA Immediate Past President Yank D. Coble Jr., MD. "If the patient isn't happy with the outcome of their visit, they don't come back, or they go to someone else," he said.
Cookbook fears unfounded
But Dr. Coble agreed that following certain standards could increase quality and said the AMA was helping lead in this area by developing clinical measurement sets doctors can use to help treat patients with type 2 diabetes, asthma, cardiac care and major depressive disorders.
He said fears that using guidelines leads to "cookbook medicine" were unfounded and explained that standard screenings for cancer, hypertension and cholesterol all provide useful patient data. How physicians use this information is up to them.
"The process is the same, but the approaches to patient care can be different," Dr. Coble said, adding that the reports offered direction for even more quality improvement.
Produced by the U.S. Agency for Healthcare Research and Quality, the reports were the first of their kind and will now be released annually.
Findings from the disparities report included: Blacks have a 10% higher cancer incidence rate and 30% higher cancer death rate than Caucasians; African-Americans, Hispanics and Native Americans have higher diabetes death rates; and blacks are more likely to have diabetes-related end-stage renal disease. Only 23% of people with hypertension have it controlled, and only 62% of smokers are advised to quit by their doctors.
"You have to tackle issues one at a time," Dr. Hampton said of the data on smoking. "If I have a patient who's in danger of going into a diabetic coma, I work on that first, but I always tell them 'Down the road, we're going to work on your smoking.' "
Dr. Hampton said physicians at Circle Family Care, located in Chicago's Austin neighborhood, work hard to provide an environment similar to the "medical home" idea.
He delivers babies as well as providing primary care. "We don't have to pass patients on to another doctor, and they don't see an unfamiliar face when they deliver," he said.
Dr. Hampton acknowledged that many blacks distrust the health care system and often believe white doctors in black neighborhoods care more about collecting fees than helping patients. This is something the CFC staff works to overcome.
"We have a lot of dedicated physicians," he said and, once patients recognize that dedication, African-American patients give the white doctors some of the same trust they give the black doctors on staff.
Dr. Coble said the value of trust cannot be underestimated and that a mobile society and managed care policies had caused damage.
"A very important ingredient of quality care -- continuity -- was interrupted," he said. "People's compliance with physician recommendations is based a great deal on trust, and trust comes with continuity and getting to know someone over time."