A common and somewhat implicit assumption is that discrimination is a prerequisite for disparities. However, disparities may exist in the absence of discrimination, such as economic/business decisions that result in disparities as an unwanted — but predictable — secondary consequence. While discrimination should never be ignored where it plays a role, the importance of economic incentives in driving disparities is too often overlooked. The Harvey L. Neiman Health Policy Institute® (HPI) is researching how economic incentives and supporting health policy can ensure more equitable access to radiology services.
To understand how economics may lead to disparities, consider geography. We know there are substantial differences in economic prosperity across communities, such as between rural and urban residents, or within an urban area. Yet, even high-income rural residents would have less opportunity to prevent, detect, treat, and survive disease than their urban peers due to the geographic proximity to equivalent medical care. Availability of new medical technology is a common issue in both rural facilities and urban facilities that serve low-income communities. These availability and access issues often have economic factors as a root cause. To the degree that proximity to technology matters, it will also yield disparities as an unwanted but predictable secondary outcome.
As imaging technology advances and becomes more costly, it takes a larger population of patients to justify allocating this technology to a specific location. There must be a return on investment. Research shows that more affluent areas are the first to have access to new medical technology. Such areas will have a higher concentration of patients with commercial insurance, which typically pays 1.2 to 1.8 times more than Medicare for physician services.1 For radiologic services, that range is 1.2 to 2.8.2 Hence, some supply-side economic factors result in disparities that are unrelated to discrimination. We ignore a host of incentives if we assume that, absent discrimination, the distribution of outcomes would be identical across groups.3
Urban safety-net hospitals demonstrate these economic realities in the care for low-income populations. Unfortunately, neither not-for-profit status nor altruistic motivations negate the financial constraints. Even the most altruistic of organizations cannot fulfill their mission if they are not financially viable. While such organizations may wish to do more, constraints matter.
Economically driven disparities are not a failure of the medical community. Because healthcare organizations must remain financially viable, they cannot ignore the economic incentives they face. For the medical community to reduce disparities, their well-meaning efforts within the scope of their practices alone is akin to treating the symptoms rather than curing the disease. To address the disease requires changing the incentives so that it is financially sustainable to serve various populations equitably.
To explore these issues, the HPI has been conducting a series of studies on disparities using access to breast cancer screening as its area of focus. Prior research has shown devastating statistics including 40% higher breast cancer mortality for Black women compared to White women.4 In the transition period from the use existing technology to newer technology as the standard of care, we found disparities in the use of the newer versus older screening technology, such as tomosynthesis compared to 2D mammography for women with the same insurance (manuscript currently under review). This disparity lessens as newer technology becomes universal — but the problem is not improving. Medicare reimbursement relative to resources committed (i.e., cost of the technology plus interpretation time) was less with tomosynthesis compared to previous technology. Not surprisingly, safety-net hospitals — which are more reliant on public insurance — are slower to adopt tomosynthesis, creating an economically driven disparity. CMS has the opportunity to reduce these disparities by adjusting reimbursement to incentivize investment in new technology.
Related to the HPI’s study of transitional disparities, Jinel A. Scott, MD, MBA, RSNA member representative to the RHEC, says, “Urban safety-net hospitals are burdened with addressing the long-term effects of historical, government-promoted and -sanctioned systemic discriminatory practices perpetrated on the disadvantaged communities they serve. To reverse the legacy of poorer health outcomes that these policies produced, the government should utilize economic policies and incentives that would allow safety-net institutions to facilitate access to newer medical technology.”
In another study in progress, the HPI identified disparities in mammography rates for Native American women compared to White women or women of other races/ethnicities. The findings suggest the effects of rurality on mammography screening rates are worse for Native American women, and income is less of a protective factor for Native American women than for other groups of women.
Where to physically locate screening technology is a business decision that yields disparities as a byproduct. CMS as a payor could lessen such disparities with reimbursement policy or other financial incentives. According to Jacqueline A. Bello, MD, FACR, chair of the ACR BOC, “We are striving to leverage radiology’s central role in achieving health equity, but as long as reimbursement policy continues to drive disparities, addressing them will be an uphill battle. The HPI plays a critical role in framing and broadening the health equity discussion.”
It is the HPI’s hope that its research program serves as a launching pad to shift the discussion of health equity to broad-scale policy that creates incentives that make equitable care a sustainable path for hospitals and radiology practices.