Healthy Skepticism Library item: 709

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Publication type: news

Medicare to Test Ways to End Disparities Amid Evidence That Closing Treatment Gaps Saves More Lives Than R&D
Washington Health Policy Week in Review 2004 Dec 23

Full text:

The Medicare program announced Thursday the details of a program to test ways to close racial disparities in access to health care, amid recent findings that more lives would be saved by closing the gap than from investing in medical research. The program calls for nine pilot projects to identify promising ways of increasing screening, diagnosis, and treatment of cancer in ethnic and racial minorities. The findings will be used to “improve the effectiveness of the Medicare program,” the Centers for Medicare and Medicaid Services said in a Federal Register notice Thursday.

Narrowing disparities is the subject of an increasing number of research projects and government programs but is a relatively low priority on the congressional health agenda. There are signs that may be changing, however. Senate Majority Leader Bill Frist, R-Tenn., has named the issue among his top priorities in the 109th Congress.

A study in the current issue of the Journal of Public Health gives a powerful argument to those who are trying to elevate the issue on the nation’s priority list. The study found medical advances saved 176,333 lives from 1991 to 2000. However, ending disparities in the death rates between African Americans and whites could have prevented 886,202 deaths during that period.

“Five deaths could have been averted for every life saved by medical advances,” said the authors of the study, led by Steven H. Woolf, M.D., of Virginia Commonwealth University. “The prudence of investing billions in the development of new drugs and technologies while investing only a fraction of that amount in the correction of disparities deserves consideration.”

While differences in access to care in part reflect differences in access to insurance coverage, such variations exist even within covered populations, such as Medicare beneficiaries. The Medicare program seeks applications from various groups to run the pilot programs, including disease management organizations, health insurers, physician group practices, academic medical centers, cancer treatment centers, community health centers, and tribal organizations.

Each of the four following groups will be the subject of at least two pilots: African Americans; Hispanics; American Indians; and Asian Americans and Pacific Islanders. Applicants must propose strategies for improving cancer care – including for breast, cervix, colon, rectum, and prostate cancer – among other requirements.

CMS plans to award funds in mid-2005. If an initial evaluation shows the projects are reducing treatment disparities and increasing beneficiary and provider satisfaction, without increasing spending, the pilots will continue. They also will continue if the initial evaluation shows they are reducing Medicare spending, the Register notice said. CMS also may increase the number of pilot programs.

CMS will grant initial awards of up to $50,000 to cover the initial phase of the program. The agency estimates that each pilot will cost $400,000 to $1.5 million per year to operate and expects them to operate for three to five years. Payments will be made on a per capita basis.

Called the Cancer Prevention and Treatment Demonstration for Ethnic and Racial Minorities, the program is required under a law passed in 2000, the Benefits Improvement and Protection Act (PL 106-554). A CMS spokesman said the pilots are being announced only now because the agency had to evaluate approaches for reducing disparities first. Those evaluations will aid in picking winning projects.

Former U.S. Surgeon General David Satcher, who was one of the authors of the study in the Journal of Public Health, said the Medicare demo “is the type of thing that is going to be important in ending disparities in health care quality.”

He noted for example, lower screening rates among minorities for cancer, including colorectal cancer, and disparities in follow-up treatment when colorectal cancer is diagnosed. Satcher also praised a requirement of the program that it include sites in the inner city.

But Satcher said “it bothers me a bit” that the program must be budget-neutral. He said the findings of the Journal of Public Health study show added funding “is an investment worth making.”

Satcher is now the interim president of the Morehouse School of Medicine in Atlanta and also has served as director of the Centers for Disease Control and Prevention.

Satcher noted the medical literature shows disparities in access to care for a variety of other conditions, including diabetes and cardiovascular disease, which he said is probably the area in which disparities are the greatest. Differences in health insurance coverage are “a major factor” in differences in access to care, “but that’s not the only factor.” Research on cardiac catheterization rates show that differences persist even when whites and blacks are in the same socio-economic group and both have insurance coverage. Proximity of health care facilities can be an issue, but racial prejudice and cultural differences between doctors and patients are factors, he indicated.

Ending disparities in early detection and follow-up care, the goal of the CMS program, would be very good steps forward. But “the approach has to include disparities in environmental exposure,” he said. He noted that higher rates of asthma in the inner city are linked to environmental conditions, including greater exposure to diesel exhaust.

“Access to healthy lifestyle is a big issue in the inner city,” he said, noting for example that it is harder to find fresh fruits and vegetables because of a scarcity of grocery stores.

Satcher said legislation introduced by Senate Majority Leader Bill Frist, R-Tenn., would address other issues that contribute to disparities, such as the lack of diversity among health professionals. Satcher said that while he supports the Frist bill (S 2091, Closing the Health Care Gap Act of 2004) “I would like to see legislation that moves us to universal access to care.”