Madara, James L. MD
Dr. Madara is executive vice president and CEO, American Medical Association, and adjunct professor of pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Editor’s Note: This is a commentary on Peek ME, Wilson SC, Bussey-Jones J, et al. A study of national physician organizations’ efforts to reduce racial and ethnic health disparities in the United States. Acad Med. 2012;87:694–700.
Correspondence should be addressed to Dr. Madara, American Medical Association, 515 N. State St., Chicago, IL 60654; e-mail: firstname.lastname@example.org.
Physician membership organizations vary in the extent of their engagement in activities to address health disparities. Increasing engagement of those organizations not already highly active in this critical area is, thus, an opportunity. Studies that provide definitional contours of key issues, like disparities, are necessary and must be iteratively refined. However, parallel activities of intervention with measured outcomes to assess the effects of these interventions are necessary to truly address major problems in the health care system. To date, work in the problem definition category exceeds work toward intervention in and mitigation of these problems with measured outcomes. Many problems in health care, including disparities, are now sufficiently understood that it is time to shift focus toward bold intervention with measured outcomes. Optimal approaches that yield superior outcomes generally require collaboration across the provider–payer spectrum and the private sectors, including physicians, hospitals, insurers, etc. Stakeholders are now free to act in such coordinated fashion; it only requires social capital that permits cooperation and compromise. Interventions for problems such as health care disparities can be developed in the private sector and mirrored by government payers if physicians and organizations can get real about collaborating to implement outcomes-based initiatives to improve the health of all patients.
In this issue, Peek and colleagues1 report an analysis of efforts by physician membership organizations to address racial and ethnic health disparities in the United States. Approximately half of the 167 organizations assessed by the authors had zero or one such active effort. Organizations with a greater focus on disparities (defined as having more than one active effort related to racial and ethnic health disparities) tended to have larger memberships, memberships dominated by racial and ethnic minority physicians, or a focus on primary care.
Critical to this study was the creation of a taxonomy of organizational disparities-related activities and themes derived from the authors’ review of the Web sites of the American Medical Association (AMA) and the National Medical Association (NMA) “selected … because these organizations have membership across medical specialties and have undertaken significant work to address health disparities.”1
The data suggest that, although physician organizations are well positioned to work toward the reduction of disparities, they could be doing much more. As examples of affirmative approaches to the problem, the authors cite the work of the Commission to End Health Care Disparities (founded, supported, and staffed by the AMA and NMA)2 and the Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,3 both of which outline strategies predicted to reduce health disparities. How, though, do we engage others throughout our health care system to address health disparities and improve outcomes for all patients, regardless of race or ethnicity?
Process Versus Outcome
Addressing a topic as critical as health care disparities requires two parallel activities. The first, into which the study by Peek and colleagues falls, are analyses which help define essential parameters of the problem—Where does the issue exist? How large is it quantitatively? What actions should be taken? Who is doing what? Such analytical work is critical and must be continued to progressively refine our understanding of the fundamental nature of the problems we face. However, as data are acquired and the dimensions of a problem understood, a second critical activity is also needed: bold innovative approaches with, most important, outcome measures to track real effects of these initiatives. We must not allow the latter pathway of outcome assessment to lag behind the former pathway of defining the problem, even after sufficient data are available to reasonably justify the launch of a major coordinated outcomes effort. That is to say, as a community, we in medicine must be as nimble at launching bold action plans with measured outcomes which access the actual effects of what we do as we are good at defining the parameters of large-scale systemic issues to be corrected. Understanding or activity should not be mistaken for results.
The Risk of Mistaking Understanding for Outcomes
Health disparity is not the only area in which the activity in the pathway for defining an important problem exceeds the activity in the pathway of assessing outcomes toward mitigating that problem. The asymmetry in the pathways related to health disparities mirrors the case of other problem areas in health care. In part, this asymmetry derives from a “chicken and egg” dilemma: It takes time to come to the point of common understanding of a problem’s existence, shape, and scale, yet this definitional work must be accomplished before launching into bold actions. For example, I would argue that we have now widely acknowledged a variety of problems in our health care system without making significant progress toward solving them: excessive variation in treatment of specific conditions, widespread lack in continuity of care, fragmentation of care, the problem of incentives that award volume over value, and many more. In these instances as well as with health disparities, we must now shift focus toward testing bold new approaches and acquiring real outcome measures to guide us to a health care system that achieves better outcomes for all patients.
What factors, other than the “chicken and egg” dilemma, potentially impede us moving to a state in which real outcomes—real value in terms of cost, quality, and equity—guide our actions? I can think of several. First, although we physicians are independent by nature, if we cannot coordinate better across the provider–payer spectrum to collaboratively roll out our own bold, innovative models for addressing systemic problems, we will create a vacuum which central regulatory bodies will attempt to fill. This would preserve our professional independence only to diminish our input into overall system-wide change. Witness the current debate on health care reform: One of the most important aspects of the Patient Protection and Affordable Care Act is its allowance for private-sector experimentation to address system-level problems. The private-sector control of health reform is within our grasp if we can compromise and coordinate with others. By such coordination with other components of the provider–payer spectrum, we would define our future and provide the models for government payers, rather than vice versa.
Second, major systemic advances are birthed of bold new actions of the type that require cooperative interaction across groups and that typically meet substantial resistance from the status quo. Whether achieving space exploration by sending a man to the moon and returning him safely, advancing the civil rights movement through coordinated nonviolent resistance coupled with compelling narrative, enhancing our understanding of biology with the human genome project, or answering some of the deepest questions of physics using the Large Hadron Collider, we must push ahead and push through barriers of inertia to accomplish systemic change. Conquering racial and ethnic disparities in health care (or any of the aforementioned big problems in health care) is no different. These historic examples from an of non-health-care topics suggest that taking this leap also creates uncertainty and contention as new systems are tested. But what was clear in those past examples, and what is clear in health care today, is that the status quo is not solving our big problems. It is equally clear that, even should we wish to (which we do not), we cannot rely on central regulatory action to solve them, given the persistent state of impasse in our government. Perhaps this impasse, although unfortunate, is the opportunity that will force us to act in the private sectors of health care to address our big problems.
Using Available Capital to Solve Systemic Problems
To achieve real outcomes success in these complex areas requires coordination of three types of capital: human, financial, and social. Our human capital is superb—we have the best, most skilled, and most highly trained physician workforce that has ever existed. We worry greatly about our financial capital given the state of our economy, government dysfunction, looming restrictions on GME funding and reimbursement, and other things, such as the threat of the so-called sustainable growth rate cuts to physician Medicare reimbursement. However, the United States deploys more than $2.5 trillion per year (>15% of our gross domestic product) toward health care. One can convincingly argue that we misapply these dollars—administrative costs and duplication come to mind—but it is hard to argue that we lack financial capital. It simply needs to be deployed in vastly different ways.
The third type of capital, social capital—the type of capital that allows us to act systemically via integration of physicians of various specialties, hospitals, payers, and others—is clearly where the rate-limiting barrier to system improvement resides. This insufficiency in social capital is a barrier that entrenches fragmentation, is permissive to administrative waste, and inhibits optimal progress toward real improvements in outcomes of health care cost, quality, and equity. Given the unique capabilities of our physicians, based on their extraordinary training and dedication, physicians need to be leaders toward a future that includes enhanced health care outcomes. This may be the only way out of our current state of inaction. Such an effort will require thoughtful compromise, an ability to see the system from the vantage of others, and deep systems thinking to leaven our fierce sense of independence, which serves to attenuate, not enhance, social capital.
In speaking with leaders of nonphysician organizations in the health care provider–payer spectrum, it is clear that they feel a need for such cross-group collective action, but it is also clear that they are dubious that physicians can participate in the kind of collective, compromising discussions that need to take place. I think they are wrong. If we as physicians prove them wrong by our participatory actions, we can lead in addressing our myriad tough problems—ones like the unacceptable state of health disparities—while also creating a health care practice environment that is thriving for current physicians and attractive to future generations. Not surprisingly, a good deal of the current strategic evaluation in national physician organizations centers on these needs.
The tipping point toward real outcomes measurement and cooperative interactions across the provider–payer spectrum in the private sector has arrived. Let’s get real.
Acknowledgments: The author thanks Modena H. Wilson, MD, MPH, Bernard Hengesbaugh, and Ken Sharigian, PhD, for reviewing this commentary.
Other disclosures: None.
Ethical approval: Not applicable.
Disclaimer: The views presented here are solely those of the author and, thus, are not meant to represent the position of any organization, including the American Medical Association.