Can Your Patient's SES Status have an Adverse Effect on You?
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP Assistant Professor, Dept. of Internal Medicine, Meharry Medical College Nashville, TN Dr. Gupta reports no financial relationship to this field of study This article originally appeared in the February 29, 2008 issue of Internal Medicine Alert. It was edited by Stephen Brunton, MD, and peer reviewed by Gerald Roberts, MD. Dr. Brunton is Clinical Professor, University of California, Irvine, and Dr. Roberts is Clinical Professor of Medicine, Albert Einstein College of Medicine. Dr. Brunton is a consultant for Sanofi-Aventis, Ortho-McNeil, McNeil, Abbott, Novo Nordisk, Eli Lilly, Endo, EXACT Sciences, and AstraZeneca, and serves on the speaker's bureau for McNeil, Sanofi-Aventis, and Ortho-McNeil. Dr. Roberts reports no financial relationships relevant to this field of study.
Synopsis: A physicians' survey in Connecticut indicates that a patient's socioeconomic status (SES) affected their clinical management decisions.
Source: Bernheim SM, et al. Influence of patients' socioeconomic status on clinical management decisions: A qualitative study. Ann Fam Med. 2008;6:53-59.
One of the top priorities for both the national Institutes of Health and the Healthy People 2010 program is to eliminate health disparities among different segments of the population. The widespread and diverse nature of healthcare disparities is well documented. Socioeconomic status (SES) influences healthcare quality and outcomes. SES is a composite attribute, which may include features such as income, education level, insurance status, access to care, patient's beliefs, and factors such as trust and communication between the patient and the healthcare provider.
In their study, Bernheim and colleagues examine how a patient's SES influences the physicians' clinical management decisions. They achieved this task by investigating physician perspectives on how the patients' SES ultimately influences their clinical management decisions. In this project, Bernheim et al conducted a qualitative study without any previously described theoretical framework and interviewed 18 primary care physicians from diverse backgrounds, most caring for Medicaid patients in the State of Connecticut. Most physicians (15) were randomly identified and contacted for interview, and three additional were identified as either minority or those caring for veterans. Physician investigators interviewed all the participants, and line-by-line coding was performed, from which recurrent themes emerged that characterized the experiences of the participants.
When asked to characterize the low SES of their patients, most physicians included positive, negative, or both descriptors. Their attributes for low SES included not only the uninsured and unemployed but also those of minority race, low educational achievement, poor social networks, and low health literacy and health behaviors, as well as those who were appreciative and interested in health. Four major themes emerged from the interviews: 1) Physicians held conflicting views about the effect of patient SES on clinical management. As a common trend, the physicians stated the notion that the low SES should not influence the standard of practice. Most, however, recounted circumstances where they had to do just the opposite. 2) Physicians believed that changes in clinical management due to patient SES were made in the patient's best interest. The physicians often adjusted their expectations of the practice of medicine to the "ground zero" reality. 3) Physicians varied in the degree to which they thought changes in clinical management influenced patient outcomes. Overall, the physicians indicated that the clinical management decisions made to accommodate with the low SES could compromise outcomes but not always. 4) Physicians faced personal and financial strains when caring for patients of low SES. They often experienced a dilemma between maintaining a consistent standard of care for everyone and providing "appropriate care," which was not standard, given a patient's SES. They expressed frustration over longer time spent with these patients, and questioned the sustainability of the current healthcare system.
Commentary
The contribution of the magnitude of the effect of SES towards health disparity has yet to be quantified. However, it is clear that SES has a direct impact on a patient's health, as well as those that provide healthcare. With the steady rise in the number of uninsured Americans, understanding this concept gains more significance now than ever before for health policy makers. Rather than blindly adopting initiatives that sound good but have yet to conclusively prove benefits, such as pay for performance (P4P), we ought to be more focused on eliminating healthcare disparities. Perhaps, P4P has been relatively effortlessly accepted because it virtually serves as a self-fulfilling prophecy; in other words, it's a win-win situation for everyone. On one hand, we are able to gather "data" that show progress is being made on achieving certain pre-specified "performance targets," while concurrently providing physicians incentives in place of adequate compensation. However, such policies fall short at the most fundamental level, providing care to those who need it the most.1 These disparate populations of patients in the lower SES remain at the mercy of our ever-collapsing safety nets and the shrinking population of physicians who care for them and value service over compensation. As a result, our vacillating healthcare delivery system expects a certain standard of medical care, but is unable to truly afford one for each of its citizens.
This is where I am reminded of the John Rawls' alternative distributive principle, which may have its own critics, but in essence, it proposes a system that allows allocation that does not conform to strict equality, so long as the inequality has the effect that the least advantaged in society are materially better off than they would be under strict equality. Thus, while we should applaud physicians such as those interviewed who are keeping the least disadvantaged over the safety net, we should simultaneously strive for a better healthcare delivery system. Healthcare should be viewed as a common social good, not just another commodity and, therefore, supplied as a need, not as a want.2 It should also be clearly understood that no amount of P4P will ever improve quality or efficiency as long as healthcare disparities persist. In fact, we must be careful to ensure that such delivery system reforms do not work to widen the already existing gaps.3,4
References
1. Casalino LP, et al. Will pay-for-performance and quality reporting affect health care disparities. Health Aff (Millwood). 2007;26:w405-414.
2. Franks P, Fiscella K. Reducing disparities downstream: Prospects and challenges. J Gen Intern Med. 2008; [Epub ahead of print].
3. McMahon LF Jr, et al. Physician-level P4P DOA? Can quality-based payment be resuscitated? Am J Manag Care. 2007;13:233-236.
4. Coleman K, Hamblin R. Can pay-for-performance improve quality and reduce health disparities. PLoS Med. 2007;4:e216.
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