1) Structural issues within health care delivery are implicated in health care disparities. Please brainstorm 4 structural issues that might contribute to these disparities. Which of these are relevant to your particular area of research, and how?
ANSWER: Four structural issues that could contribute to these disparities are listed as follows: fragmentation of healthcare financing and delivery, large patient loads on PCPs and little to no face to face interaction between PCP & patient, low proportion of health professionals who are minorities, little to no financial incentives for PCPs to reduce barriers and practice evidence based medicine.
Due to fragmentation of healthcare financing and delivery, minority patients are more likely to be enrolled in “low-end” or low quality healthcare plan less options and strict limitations (i.e. less flexibility in treatment options, reduced access to care). Overworked PCPs with a lot of patients and little time will often use “gesalts” to evaluate patients; this could lead to increased mistrust between PCP and patient, particularly if patients feel rushed.
A low proportion of minority health care providers means patient won’t see people who look like them reflected in the healthcare system. This could reinforce mistrust in the healthcare system and discourage Black, Hispanic and Asian patients from seeking medical attention. Last, many Pediatric dentists will not accept Medicaid because the reimbursements are so low compared to other dental insurance; this makes it difficult for children who use Medicaid to find a dentist. Giving dentists who accept Medicaid additional financial incentives would increase the number of dental providers that accept children on Medicaid
All four of these structural issues are relevant to my area of research (genetic influence on response to metformin). Modulating these issues would influence primary care practice, where primary prevention, education and treatment of Type 2 Diabetes primarily occurs. “De-fragmentation” of health care financing and delivery could increase the number of providers eligible to take on Medicaid patients, improve the quality of health plans primarily offered to racial and ethnic minority groups who bear a large burden of the incidence of Type 2 Diabetes. Health-plans that increase treatment flexibility will give patients more pharmacological and non-pharmacologic treatment options. Reducing patient loads on PCPs will decrease stress and time constraints on these practices. This will allow for better, high quality patient-provider interactions, better communications, and increase sense of patient satisfaction. More racial/ethnic minority health care providers will improve culturally-sensitive care that is tailored towards patients of racial and ethnic minorities. Increasing financial incentives should increase the number of PCPs willing to provide care to Medicaid/Medicare patients. Reduced reimbursements offered for Medicaid patient care can be offset by additional financial rewards. Further rewards can be offered by showing decreased clinical outcomes that influence public health.
2) How do individual physicians contribute to health care disparities? Thinking about an area of health care of particular interest to you, what research do you think could be done to either understand the effect of individual physicians on health disparities, or to decrease this effect?
ANSWER: Individual heath care providers bring in there own conscious and unconscious bias towards patients of racial and ethnic minorities (making assumptions regarding how these patients understand their disease processes, treatment adherence, etc). An observational study of PCPs direct interactions with actor-patients would be good (of course getting providers to consent to the study would be challenging). Specifically, I would choose Caucasian MDs (male and female), Black MDs, and Hispanic MDs and use patient actors (to simulate metabolic disease processes). It would occur in the practices where they normally work. Doctors would be blinded to whether it’s a real patient or a patient-actor. The patient actor would visit each doctor and comparisons would be made between the care received from each doctor. The endpoints evaluated would include all clinical guideline-based recommendations for that metabolic disease. After collection, I would statistically analyze differences between endpoints in the clinical interactions of Caucasian MDs, Black MDs, and Hispanic MDs and the differences between Caucasian male MDs and Caucasian female MDs.