Starting With Curious

I am a racist.  There, I said it.

I don’t mean an Archie Bunker-type bigot who hurls invective and spews hate.  But view the world through the concept of race, the idea that characteristics are bundled together, and that knowing the color of someone’s skin can be informative about what is inside.  That is the essence of racism: the idea that race is determinative, that people of different color differ in other important ways.  (Some prefer to refer to this as racialism, but let’s just call a racist a racist.)

Now, I didn’t say I believe it; actually, I do not.  But being honest with myself, I’d have to admit that when I encounter someone I don’t know, I reflexively begin to make assumptions about them based on their appearance.  I do not consciously accept the concept of race, but my instincts are otherwise.  When I see a patient in the emergency department who is black, I make assumptions about the fact that they probably live in the city of Milwaukee, and they are likely to be insured by Medicaid.  I virtually always catch myself, and I work furiously not to allow that initial assumption to enter into my thinking and actions.  But no matter how good I am at suppressing it, I can’t deny it came up.

I’d be willing to bet a decent amount of money that everyone reading this is also a racist.  No doubt, you do your best, like me, to overcome it, and you probably don’t ever do or say anything that would be considered “racist” in the common use of that word.  But it’s probably inevitable.  In large part, it is a manifestation of the way our minds process information.  I have written previously about heuristics – mental shortcuts our brains use to reach conclusions more efficiently. These heuristics are based on our prior experiences and on statistical facts about groups.  When a child encounters a dog for the first time, she is unlikely to be fearful.  If her first experience results in being bitten, she will instinctively react with caution to dogs in the future.  Even those of us who have never been bitten are likely to be more leery around pit bulls, based on reports (which it turns out are probably wrong) that the breed accounts for the majority of bites.

We live in a society where, statistically, there is an association between, for example, race and poverty, or race and crime.  In that sense, the heuristic isn’t wrong.  It’s true that in our ED, black patients do largely live in the city of Milwaukee, and are disproportionately poor.  We run into trouble in at least two ways.  First is when we take a true fact about a group and apply it to an individual.  Even if it’s true that more blacks in this area are more likely to not finish school, it is an affront to the inherent worth and dignity of each person to make any assumptions about an individual black person’s educational level.   When we deal with a person, we cannot use mental shortcuts.  But to overcome them we must acknowledge them.

It’s also a short and slippery slope from seeing an association to seeing causation.  Many people are too willing to make the leap from “black people are more likely to live in poverty” (a true if unfortunate fact), to “black people are poor because they are black.”  Therein lies the kind of thinking that people commonly associate with the term racism.  And racism in this sense is still too prevalent in 2014.

Just six years ago, in the aftermath of President Obama’s election, we were hearing about how America had become “post-racial.”  Now, it seems that race relations are in the worst shape I can remember.  What went wrong?

If the first step toward a solution is admitting there is a problem, we have to accept that we are, nearly universally, racist.  It takes a lot of mental effort to override our heuristics.  Pretending racism is something that only overt bigots experience, it’s too easy to let down our guard.  It also closes off conversation.   The inherent racial thinking that we all have is pretty obvious to most members of racial minorities, but less so to those of us in the majority.  Denying it invalidates their experience and prevents us from building the kind of connections that might mitigate its effects.

I’d love to think we can actually get beyond the idea that skin color has anything to do with any other inherent characteristics – we don’t tend to draw the same conclusions based on hair or eye color, after all.  Not that there hasn’t been some progress.  Some medical journals, for example, will not accept analyses based on race unless there is a clear biological explanation (e.g., a study involving actual skin pigmentation).  Too often race is used as shorthand for socioeconomic status or educational status; such reporting simply reinforces the stereotypes and does nothing to contribute to our understanding.  But race seems such an entrenched part of the way of looking at the world, it’s hard to imagine a “post-racial society” anytime soon.

In the meantime, if rational thinking is to prevail over instinct, need to accept that regardless of our best intentions, we all view the world through the lens of race.  Go ahead, say it.

I found the same book on Amazon.com for prices ranging from ten cents to ten dollars.  All were new; the cheaper ones were publisher overstocks so they had a stamp on the inside front cover, but it was hard to argue that it was worth paying more than three times as much (after adding in the shipping) for something I would never notice in reading the book.  Even if I hadn’t been raised by an accountant, I would have picked the cheaper one (which I did).

So how can one justify the variability in costs for fairly standardized things in medicine, such as the more than ten-fold difference in prices for an echocardiogram, even within a metropolitan area?  Traditionally, providers of those services have relied on the fact that consumer choice was almost non-existent.  First, in the paternalistic world of medicine, patients frequently deferred to their doctor’s recommendation, asking few questions.  There was no incentive for shopping on price for those with insurance, and the costs were often too high for those without to even consider seeking care.  And even if one wanted to comparison shop, pricing information was at best difficult to obtain.

Recent studies provide a glimpse of the effect of consumerism – driven by the rise in high-deductible plans and other factors that have placed more financial risk on patients – on both prices and spending in healthcare.  A study in Health Affairs examined the effect of providing pricing information on MRIs without a connected financial penalty.  Members of health plans that provided price information on MRI options spent an average of $220 less than those who did not have access to the information.  Moreover, in those regions where the pricing transparency was implemented, the range in prices for MRIs among facilities in that region decreased by 30%, mainly due to lowering of prices by the most expensive providers.  No similar price change was seen in the control regions.  Another study in JAMA looked at variation in healthcare spending between people who did or did not use an on-line calculator to research out-of-pocket costs before seeking care.  Those who searched for information chose lower priced services for laboratory tests and imaging (but not for providers) than those who did not search for the information.  Interestingly, the difference was similar for those with and without cost sharing.  It was not clear that utilization was affected, only that given price information people seek lower prices.

These and other studies show that, despite what we providers might like to think, price does matter to patients, and even without punitive levels of cost-sharing, people will seek lower prices when they have the information.  But of course, price is not the only thing, or even the most important.  Quality matters.   In recent years we’ve referred to this as “the value proposition.”  But this concept has been around for a long time; the older and wonkier term is “cost-effectiveness.”  Which is why it is disappointing and puzzling that making data on cost-effectiveness available has been seriously hindered.  The ranting about “death panels” was a reaction to the idea that giving elderly patients information about cost-effectiveness of end-of-life options was at best “rationing,” and at worst one step away from the world depicted in the movie “Soylent Green.”  The Patient Centered Outcomes Research Institute (PCORI), established as part of the Affordable Care Act, was intended to be able to provide the sort of data to inform consumer choices in medical care.  Yet the law explicitly prohibits PCORI from funding or conducting cost-effectiveness research!  This is crazy.

Medical consumerism is here.  It is affecting the way patients choose, and it is affecting prices.  If people are to make good choices, we need more transparency, and more good data on cost-effectiveness.  If Amazon can do it, so can we.

Disparities in the criminal justice system have replaced health disparities in the headlines recently.  Is this because health disparities have improved?  Some recent articles confirm my suspicion that the answer is mostly no.

Two New England Journal of Medicine articles and one editorial examine this question.  In one article, researchers examined racial differences in performance on 17 process-of-care quality measures – for example, did patients with heart attacks or pneumonia receive appropriate medications.  In 2005, quality of care was substantially worse for black and Latino patients compared with non-Latino whites.  In 2010, the performance gap had improved substantially.  That seems like good news.  However, in another article in the same issue, racial differences in actual health outcomes (such as control of high blood pressure or diabetes) among Medicare recipients persisted from 2006 to 2011 nationally, though there were improvements in some regions.

How to reconcile these two reports?  Of course the populations and methods are somewhat different.  But a larger point is that reducing disparities in health care does not necessarily translate to reducing disparities in health.  Health care is one of many determinants of a person’s health, and only accounts for about 10% of health status.  The remaining 90% is due to genetics, behavior, and environment.  Improving health takes a lot more than improving health care.

Even in regard to disparities in care, the evidence is not necessarily encouraging.  The findings of an article in Pediatrics were fairly provocative.  Using national data, authors found that adherence to prescribing guidelines for otitis media was actually better for black children than non-black children, which seems like good news.  However, the difference was due to less prescribing of broader-spectrum, more expensive (and not recommended) antibiotics for black children.  These national data confirm early, localized findings from other studies.  While it would be nice to attribute this to more diligence by providers when treating blacks, a more realistic explanation is less parental pressure for expensive antibiotics – or more likely less anticipation by the provider of such pressure – for blacks compared with whites.  The authors of an accompanying editorial describe this as an example of “structural racism.”

Eliminating health disparities is going to take more than changing prescribing.  It will require addressing those behavioral and environmental factors that are the primary determinants of our health.  It means Ferguson, MO needs to have more in common with the nearby but much more affluent suburb of Ladue.

There are many ironies of the term “health care” as currently used, especially in the US.  Not the least is that actually keeping people healthy is financially punished.  But an irony that is not as often discussed is the enormous adverse environmental impact that hospitals and other medical facilities typically have.  For example, hospitals produce nearly 12,000 tons of waste per day, an average of 26 pounds per bed.  They are also major consumers of water and energy.  Hospitals are among the most energy-intensive facilities; they account for 8% of all of the nation’s energy use.  The resulting waste and emissions of carbon and other pollutants adversely affect the health of a community, in the name of providing health care.

Some systems are working to change that.  In October, Gundersen Lutheran Health System in La Crosse, WI, became the first health system in the US to be energy independent, generating more energy than it consumed.  In 2008, Dr. Jeff Thompson, Gundersen CEO (and a pediatrician!) set a goal of energy neutrality as way to reduce cost and lower the negative impact of the facility on the health of the community.   They achieved this through a combination of conservation (a 40% reduction in energy use, saving roughly $2 million a year to the system despite a 25% increase in the size of the facility over the same time) and development of renewable, non-polluting energy sources like geothermal, wind, and biomass, through both local projects and regional partnerships.

We want the kids in Wisconsin to be the healthiest in the country.  This won’t happen without, among other things, a healthy environment.  Gundersen Lutheran is doing its part to ensure that.  What more could we do?