Editor’s note: This post is part of a Health Affairs Blog symposium stemming from “The New Health Care Industry: Integration, Consolidation, Competition in the Wake of the Affordable Care Act,” a conference held recently at Yale Law School’s Solomon Center for Health Law and Policy. Links to all posts in the symposium will be added to Abbe Gluck’s introductory post as they appear, and you can access a full list of symposium pieces here or by clicking on the “Yale Health Care Industry Symposium” tag at the bottom of any symposium post.
How will health care consolidation affect health and health care disparities? How will it affect minority and low-income communities? We don’t know, and that’s the problem.
Health care consolidation may offer some promise, and potentially some peril, but we should determine how it impacts those communities with the poorest health and thereby addresses health inequality. After all, those who have the means can already access the greatest medical services, technology, and expertise in the world. Our global rankings in health outcomes do not match our health expenditures because of the disproportionate health burdens suffered by low socioeconomic communities. They are subjected to poor health services, if they receive any at all.
How, then, does consolidation address barriers these vulnerable citizens face, such as geography, cost, and a lack of profitability in addressing many of their health needs? If we are to accept the proposition that consolidation will lead to integrated health care, those who are already receiving the benefits of our current system will inevitably be rewarded. But is there evidence that these benefits will trickle down to those who suffer most?
Medicaid As A Bellwether
At Total Health Care, a free clinic in Baltimore where nearly 70 percent of patients are covered by Medicaid or the Children’s Health Insurance Program (CHIP) and up to 60 percent live in severe poverty, most of the patients need general medical treatments. Some of their greatest needs are treatment for substance abuse, mental illnesses, or dental work — not the advanced medical technology services frequently mentioned as a benefit of mergers. Therefore, will consolidated providers take steps to improve their services for these populations, especially for those covered by Medicaid? Or will they focus their attention on improvements that are more likely to appeal to those who can improve profitability?
And how does the continuing trend of consolidation affect access for Medicaid patients more broadly? Low Medicaid reimbursement rates and the expanded Medicaid coverage from the Affordable Care Act (ACA) are often used as a justification for the need to merge providers. Yet, is there evidence that consolidated providers, who have increased their privately insured patient population, are accepting more Medicaid patients? Clarifying the impact of consolidation on Medicaid patients specifically may help clarify the effect on low-income populations more generally.
The Role Of Social Determinants Of Health
Moreover, health disparities do not arise only, or even primarily, from health care disparities; heath disparities instead stem largely from social determinants of health that differentially affect minority and low-income communities. The water issues in Flint are an unfortunate reminder that health can no longer be narrowly addressed through improvements in health care services. What good is increased insurance coverage and improved medical technology for those consuming poisoned water from birth?
And this is not just in Flint. As one article rightly pointed out, “America is Flint!” While 4.9 percent of children in Flint have elevated levels of lead, in the most recent data for Iowa 32 percent of tested children had elevated lead levels. The Centers for Disease Control and Prevention (CDC) estimates that 535,000 children between the ages of 1 and 5 suffer from lead poisoning, which research has associated with impaired cognitive development associated with violent and criminal behavior.
Lead poisoning is not the only condition plaguing marginalized populations in this country. There is poor air quality, suffered due to substandard housing conditions or local pollutants. Children’s exposure to air pollutants has been strongly associated with poor academic performance, and research has shown that race and class are the greatest predictors of exposure to environmental hazards. Meanwhile, air pollutants have been associated with such adverse health outcomes as diabetes, cancer, low birth weight, as well as preterm birth.
Exposure to lead and toxic air are simply two examples of the impact that social determinants of health can have on vulnerable communities. And if we are unable to provide sufficient clean air and water, two of the most essential requirements for life and fundamental human rights, there should be serious concern about our ability to address other social determinants.
“Health disparities are rooted in the social, economic, and environmental context in which people live.” Existing literature on consolidation addresses important aspects of the health care delivery system, and certainly quality and cost of care are important factors that cannot be ignored. Yet, research demonstrates that health care is a relatively weak health determinant. For example, the most important determinants of premature death are smoking, diet, and exercise. One study found that over a third of the annual total deaths in the United States are associated with social factors, including education, racial segregation, social supports, and poverty.
Medical-Legal Partnerships
With the United States already spending disproportionately less on social services than on health care, does a larger health system enable a provider to establish more social services for their patients, or further address social determinants of health? There is little discussion from the proponents of consolidation that this is the case, but it might make for a stronger argument than the need for bargaining power.
For example, Medical-Legal Partnerships (MLPs) have been shown to promote health equity: One recent study showed that a majority of the barriers to housing for homeless veterans were legal in nature; another study revealed that at one hospital every high-need, high-cost patient had serious, health-harming legal problems. Will consolidated providers, with their increased revenue, hire more attorneys to help promote the health of their patients, or to tend to their next contract negotiation with insurance companies?
This is not to hold providers, or consolidation generally, responsible for addressing all social determinants of health. But if the structural, social, economic, and environmental barriers to health are not going to be addressed through consolidation, it must be asked what consolidation will do specifically for those who need the most help. If it improves providers’ ability to address social barriers to health through MLP expansion, or tackle the most pressing health problems of the poor, or see more Medicaid or uninsured patients, perhaps there is a stronger moral or ethical claim for consolidation than has been made thus far.
A Forward-Looking Research Agenda
A zip code is a stronger predictor of a person’s health than their genetic code. If “Big Med” is going to increase standardized methodology and reduce costs and in-hospital harms, will those in rural communities have access to these benefits? Will larger health systems expand their services to low-income communities, or will they swallow up and shutter the doors of smaller competitors who may serve these populations? Are free clinics and community health centers going to be left to deal alone with the overwhelming health burdens suffered by the poor and rural communities?
The point is not to denigrate what has been done to analyze the impact that consolidation has had, and will continue to have in the future. Rather, it is to suggest that researchers and academics must do more work on how, if at all, consolidation impacts health disparities. Consolidation is not integration, and what we need is evidence that the former does in fact lead to the latter — and not just integrating health services, but integrating those services into a system that addresses the needs of the underserved holistically. Absent this evidence, it becomes likely that the merger frenzy is a rush to strengthen bargaining power focused more on shareholders and bottom lines than on health outcomes.
Consolidation as a means to improve the care received by those who already have access to the best services lacks moral justification. As such, we cannot continue to only evaluate the benefits of consolidation, if any — we need to start examining who receives these benefits. We must focus on whether consolidation ameliorates the disparate burdens that poor and minority communities face and whether it addresses the factors that most impact their health.
from Health Affairs Blog http://ift.tt/1nrwO4p
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