Confronting the uncomfortable: health plans and health disparities: a moral dilemma in a morally driven industry.

Abstract

American medicine was traumatized when, in the 1970s, it was revealed that hundreds of African-American men were purposefully denied treatment for syphilis for decades at the Tuskegee Medical Institute.1 For two centuries, American medicine had never confronted the mythology that the practice of medicine was above the fray of power structures that reinforced the status quo. Historically, physicians have characterized their profession as the practice of the “art of medicine.” The Hippocratic oath inspires young doctors to apply biological knowledge to comfort and to help other human beings, regardless of their background. The complexity of human interactions leads to an infinite set of outcomes and expectations and, as an “artist,” a physician works earnestly to manage conditions resulting in comfort and wellness. Health plans, in contrast, exist to efficiently organize thousands of individualized encounters by harnessing the power of technology and managing and parceling services to optimize health and mitigate the impact of illness for a defined group of individuals. In effect, health plans have become the invisible “third person” in the exam room, exerting a ubiquitous influence on what had been historically considered a hallowed relationship between physician and patient. Accordingly, the predominant view of health plans (ie, insurers) is that of a necessary, but not altogether welcome third-party arbiter between patient and physician. The arbiter, in this case, has rarely been regarded as a positive force for change. (It should be noted that a number of health plans, eg Kaiser Permanente, are designed with the conviction that optimal outcomes are achieved when patient care incorporates “integrated” delivery, the result of a partnership between clinical provider and insurer. Nevertheless, physicians on one hand, and insurers on the other, represent dichotomous relationships to patients as individuals.) In a generic sense, modern clinical outcomes are the result of physician-patient-health plan interactions. Indeed, thousands of hours and millions of dollars are expended annually to dissect the hidden factors that result in suboptimal population outcomes and adverse individual incidents. The resultant interplay between health plan and individual clinician ultimately defines the patient experience and the outcomes of the health care system as a whole. For the most part, America's health care system, both heralded and maligned, examines itself through the lens of diagnosis, therapy, and delivery of care. Unfortunately, this set of parameters falls short when applied to the aggregate impact of substandard care and outcomes provided to persons of color, ie health disparities. Our health care system, the composite product of health plans and clinicians, has yet rid “the damned spot” of discrimination and racial inequality and its concordant suffering. The idea that clinical outcomes are bounded by the therapeutic relationship between patient and clinician results in physician-centric “solutions” to eliminate health disparities. But if we concede that health plans do indeed have a role in defining the clinical encounter, the “third person” in the exam room then might just have a major, if not decisive role in erasing the systematic failure to achieving equity in health care. Health plans wield powerful tools that can instigate positive health care outcomes. Health plans need to harness their assets, including the collection and analysis of copious data, the provision of incentives that accelerate the adoption of positive practices, and the establishment of benchmarks for standards and quality, to be effective change agents in eliminating health care disparities. … diagnosis, therapy, and delivery of care. … falls short when applied to the aggregate impact of substandard care and outcomes provided to persons of color, ie health disparities.