opinion

Ending health disparities takes interdisciplinary approach

A message to all physicians from AMA President J. James Rohack, MD.

By J. James Rohack, MDis senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05. Posted May 3, 2010.

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While the passage of PL 111-148 and 111-152 -- the health system reform package -- was historic, it is not the final step in achieving health care reform in the United States.

One of the causes of health care disparities in the U.S. is the lack of health insurance coverage. The expansion from 83% to 95% of Americans having health insurance coverage through the health reform legislation is a positive step. But it is well documented that morbidity and mortality rates for many diseases still are higher for blacks, Hispanics, Asians, Pacific Islanders, American Indians and Alaska Natives -- insured or not.

One indicator is in the annual reports, mandated by Congress, on the state of the nation's quality and health disparity environment that are produced by the Agency for Healthcare Research and Quality. In April, the Institute of Medicine released recommendations to make those reports even more useful.

So the documentation of the disparities is well known, widely disseminated and becoming more accurate all the time. The question becomes, "Now what?"

One organization seeking the answer is the Commission to End Health Care Disparities, founded by the AMA, the National Medical Assn. and the National Hispanic Medical Assn.

The commission's focus is on promoting policies aimed at eliminating health disparities. It provides a forum for discussion of key issues relating to this goal while promoting trust, fostering respect and creating partnerships among member organizations and others seeking to eliminate health care disparities. Currently, 65 groups representing physicians, nurses, allied health professionals, insurers and industry are members of the commission.

In keeping with the commission's purpose of advocating for action -- including government action -- to eliminate disparities and to strengthen the health care system, the spring meeting of the commission was dominated by the theme of an interdisciplinary approach to patient-centered care, as viewed through the lens of how new federal health care legislation would impact health care disparities.

For example, representatives from Massachusetts gave presentations about their experience with statewide universal health coverage. These highlighted the need for a simple process to make it easier to get individuals and families signed up for that coverage.

Another cause of disparities is the pervasiveness of low health literacy in the U.S. Extending health insurance coverage to individuals who can't take part in their own health care decisions because they do not understand a physician's instructions due to cultural or language barriers will do nothing to contain avoidable health care costs.

Medication management, avoiding either the failure to take medications correctly or the failure to take them at all, is an example of a situation where an interdisciplinary approach that includes the clinician, pharmacist, social worker and community can work together to identify those with low health literacy and proactively take steps to correct the issues.

An example was given of a patient who was recently diagnosed with diabetes mellitus. After receiving the prescription for oral medications, the person took the month's supply and returned to the clinician three months later, indicating that she was delighted to be cured of her diabetes. When questioned, she said she assumed that the prescription was just like a treatment she had once received for an infection -- when the prescription ran out, she was cured.

Having a system in which a pharmacist can notify the prescribing physician of a person failing to refill maintenance medications but also in which the clinician has a follow-up mechanism or procedure with the patient would be very helpful.

The sheer numbers of people in certain populations at risk for low health literacy who lack computers and landline phones makes an alleged health care nirvana a questionable proposition at best. All health care challenges for many affected by health care disparities will not be solved with electronic medical records. In fact, it is likely that health care disparities may worsen if not addressed proactively during the changes in store as the American health care system evolves.

That is why the Commission to End Health Care Disparities will play a critical role to help guide the changes needed to ensure culturally competent patient care. Because when patients do not understand their medical conditions or what to do to control them, unnecessary health care costs will only increase. And that is a situation the AMA is committed to avoiding -- both for our patients' health, and for our country's economic future.

J. James Rohack, MD is senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05.

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