Tuesday, February 26, 2019

Bend Over and Cough

We are pretty much at the same place when it comes to medicine so why anyone would believe Physicians give a flying fuck about anyone regardless of race clearly has never actually seen a Doctor.

The rising flow of exploitation and fraud in Medicare is one flag, the closing of rural hospitals another. Then there are the massive consolidations of Insurance companies and medical providers a big flag.  Mergers, check!The fight over ACA versus Medicare for All is leading us all to debate the role of insurance in determining care. Then we have the States and their Medicaid fuck ups and largely in States that have larger percent of residents in poverty and in turn faces of color.  Lastly we have the reality that Medicine is one giant fuck hole where you are screwed but never get a turn to cum.  Yes this is American medicine at its finest.

When it comes to care there are racial discrepancies that will require an new version of The Green Book to ensure faces of color can get treatment.  Include Gender, Age, Income, and Sexuality. That is going to be a hell of a big book.

Doctors and Racial Bias: Still a Long Way to Go

It would be easy to look at a photo from the 1980s and conclude that things have changed. Many have not.

By Aaron E. Carroll
New York Times
Feb. 25, 2019

The racist photo in the medical school yearbook page of Gov. Ralph Northam of Virginia has probably caused many physicians to re-examine their past.

We hope we are better today, but the research is not as encouraging as you might think: There is still a long way to go in how the medical field treats minority patients, especially African-Americans.

A systematic review published in Academic Emergency Medicine gathered all the research on physicians that measured implicit bias with the Implicit Association Test and included some assessment of clinical decision making. Most of the nine studies used vignettes to test what physicians would do in certain situations.

The majority of studies found an implicit preference for white patients, especially among white physicians. Two found a relationship between this bias and clinical decision making. One found that this bias was associated with a greater chance that whites would be treated for myocardial infarction than African-Americans.

This study was published in 2017.

The Implicit Association Test has its flaws. Although its authors maintain that it measures external influences, it’s not clear how well it predicts individual behavior. Another, bigger systematic review of implicit bias in health care professionals was published in BMC Ethics, also in 2017. The researchers gathered 42 studies, only 15 of which used the Implicit Association Test, and concluded that physicians are just like everyone else. Their biases are consistent with those of the general population.

The researchers also cautioned that these biases are likely to affect diagnosis and care.

A study published three years earlier in the Journal of the American Board of Family Medicine surveyed 543 internal medicine and family physicians who had been presented with vignettes of patients with severe osteoarthritis. The survey asked the doctors about the medical cooperativeness of the patients, and whether they would recommend a total knee replacement.

Even though the descriptions of the cases were identical except for the race of the patients (African-Americans and whites), participants reported that they believed the white patients were being more medically cooperative than the African-American ones. These beliefs did not translate into different treatment recommendations in this study, but they were clearly there.

In 2003, the Institute of Medicine released a landmark report on disparities in health care. The evidence for their existence was enormous. The research available at that time showed that even after controlling for socioeconomic factors, disparities remained.

There’s significant literature documenting that African-American patients are treated differently than white patients when it comes to cardiovascular procedures. There were differences in whether they received optimal care with respect to a cancer diagnosis and treatment. African-Americans were less likely to receive appropriate care when they were infected with H.I.V. They were also more likely to die from these illnesses even after adjusting for age, sex, insurance, education and the severity of the disease.

Disparities existed for patients with diabetes, kidney disease, mental health problems, and for those who were pregnant or were children.

The report cited some systems-level factors that contributed to this problem. Good care may be unavailable in some poor neighborhoods, and easily obtained in others. Differences in insurance access and coverage can also vary by race.

But the report’s authors spent much more time on issues at the level of care, in which some physicians treated patients differently based on their race.

Physicians sometimes had a harder time making accurate diagnoses because they seemed to be worse at reading the signals from minority patients, perhaps because of cultural or language barriers. Then there were beliefs that physicians already held about the behavior of minorities. You could call these stereotypes, like believing that minority patients wouldn’t comply with recommended changes.

Of course, there’s the issue of mistrust on the patient side. African-American patients have good reason to mistrust the health care system; the infamous Tuskegee Study is just one example.

In its report, the Institute of Medicine recommended strengthening health plans so that minorities were not disproportionately denied access. It urged that more underrepresented minorities be trained as health care professionals, and that more resources be directed toward enforcing civil rights laws.

In practice, it endorsed more evidence-based care across the board. It noted the importance of interpreters, community health workers, patient education programs and cross-cultural education for those who care for patients.

In 2017, the Agency for Healthcare Research and Quality issued its 15th yearly report on health care quality and disparities, as called for by the medical institute in 2002. It found that while some disparities had gotten better, many remained. The most recent data available showed that 40 percent of the quality measures were still worse for blacks than whites. Other groups fared worse as well. Measures were worse for 20 percent of Asian-Americans, 30 percent of Native Americans, and one third of Pacific Islanders and Hispanics.

Of the 21 access measures tracked from 2000 to 2016, nine were improving. Nine were unchanged. Three were worsening.

It would be easy to look at a racist photo from the 1980s and conclude that it was a different time and that things have changed. Many things have not. We know that racism, explicit and implicit, was pervasive in medical care back then. Many studies show that it’s still pervasive today. The recommendations from the medical institute in 2003 still hold. Any fair assessment of the evidence suggests much work remains to be done.

And with regards to that I want to point out that this American flag runs with many colors and we are not a two color nation by any stretch. I also question treatment with regards to gender, sexuality and particularly for those transgendered.  So please lets not just be so black and white.

With the end of mandatory coverage removed expect the costs of premiums to rise.  I plan on canceling my policy once the last of my dental work is done.  I have no interest in spending 700 bucks plus a month for something I don't use and if I need it I will hit the charity roles and frankly I have no reason to pay for something that I find utterly absurd and abusive.

Covering Pre-existing Conditions Isn’t Enough

Too often, even patients who have coverage can’t afford their medications.

By Douglas Jacobs\Dr. Jacobs is an internal medicine resident.
The New York Times\Opinion
Feb. 25, 2019

When patients enroll in health insurance, they are often met with a stark reality: Even with insurance, they can’t afford their treatment. With the Affordable Care Act and its protections for people with pre-existing conditions in limbo once again, it’s important to remember that those with such conditions need more than health insurance. They also need to be protected from discriminatory pricing so that they can afford the medications they need.

In 2015 I published a paper in The New England Journal of Medicine that detailed how some insurers were raising costs for H.I.V. medicines to dissuade H.I.V.-positive people from selecting their plans. Insurers frequently raise the price of certain medicines to encourage people to select cheaper alternatives, but these insurers raised the cost of every single H.I.V. medicine — leaving many enrollees with no affordable options.

The difference for someone with a pre-existing condition like H.I.V. was staggering (in some cases more than $10,000 annually for H.I.V. medicines in one plan compared with less than $1,000 in another). This practice was later recognized by the Department of Health and Human Services as a form of discrimination by insurers.

Unfortunately, pharmaceutical companies and insurers are still getting away with raising their prices in a way that has a disparate impact on those with pre-existing conditions. A 2019 report by Harvard Law School’s Center for Health Law and Policy Innovation found that some insurers continue to price all recommended H.I.V. regimens in a way that makes them prohibitively expensive. In Georgia, for example, three out of the four insurers place all recommended H.I.V. regimens on the most expensive tiers (costing more than $1,000 a month) or do not cover them at all.

As another example, the high price of hepatitis C medicines set by pharmaceutical companies caused many state Medicaid programs to institute discriminatory prior authorization requirements. Those requirements effectively barred people who had a diagnosis of alcohol use disorder and had not refrained from drinking for a specified period of time from treatment — even though we know that hepatitis C medicines are just as successful in people who drink alcohol.

In many cases, this administration has made matters worse. With the repeal of the A.C.A.’s individual mandate by the 2017 tax bill, healthy individuals can forgo insurance altogether, causing premiums to rise for everyone else. The Trump administration also made it easier to establish association health plans and short-term plans (often referred to collectively as “junk health plans” because they aren’t required to cover many services). This forces those with pre-existing conditions to either stay in their A.C.A. plan and see their premiums rise as healthy individuals move to junk insurance because it’s cheaper, or sign up for a junk plan and risk extreme charges when services they need are not covered.

While some association health plans have received positive press, these kinds of plans are notorious for cherry-picking healthy enrollees and even committing fraud. As for short-term plans, they are simply denying coverage to those with pre-existing conditions altogether.

Fortunately, with the shutdown finally over, both sides of Congress are getting to legislating, and an issue that both Republicans and Democrats campaigned on is the protection of those with pre-existing conditions. Safeguarding the A.C.A. — by supporting its existence and by eliminating the threat of junk insurance — is a first step.

But protection also means making sure that those who have pre-existing conditions can afford plans that cover the medications they need, which requires instituting policies aimed at both insurers and pharmaceutical companies. After all, what a consumer pays for a medicine is a mix of the price set by a pharmaceutical company, the cost assigned to the drug by the insurer and countless negotiations among pharmaceutical companies, insurers and the pharmacy benefit managers that serve as middlemen.

Accordingly, the administration’s announcement to tie Medicare Part B drug prices to an international drug-pricing index should be lauded and expedited. National policymakers should also emulate California, which will band together all state entities into a single purchaser of drugs, adding leverage to efforts to negotiate down drug prices. They could combine federal employee health benefits, Medicare, Medicaid, the Department of Veterans Affairs, Tricare (the health program for uniformed service members) and other public purchasers into the largest single purchaser of drugs our nation has ever seen, one with enormous leverage to reduce drug costs. And with prices lowered, they should require insurers to keep medications affordable.

Obviously, protecting the A.C.A. comes first. But to provide meaningful protections to people with pre-existing conditions, we need to go further. Lowering the cost of drugs achieves the same end: access to care for those who need it most





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