CMS talk, policy at odds in eliminating health disparities

I read with great interest the recent Q&A “We're trying to build the business case for achieving health equity,” (April 25, p. 30), based on an interview with Cara James, Ph.D., director of the CMS' Office of Minority Health. The OMH is working to close the gap on the pervasive health disparities experienced by communities of color. As part of this effort, it has developed tools that identify areas of need and issued guidance to improve population health.

James estimated that as much as 80% of health disparities are driven by social determinants of health. Further, she asserted that structural barriers prevent the healthcare system from addressing these social factors.

Unfortunately, there's a disconnect between CMS' rhetoric and policy. While the OMH pledges to work with providers to educate them about responsibilities for providing services to people with social complexities, the CMS' Hospital Readmission Reduction Program is disproportionately stripping safety net hospitals of the resources needed to deliver on this goal. The disconnect is compounded by other CMS efforts—including the planned overall hospital quality star-rating system—that fail to appropriately adjust for the community-based health disparities that influence hospitals' ability to care for patients on the lower rungs of the social ladder.

Our data support James' assertion that healthcare needs vary significantly from “one geographic location to the next, or from one community to the next.” In fact, I was joined by David Nerenz, director of the Center for Health Policy and Health Services Research at the Henry Ford Health System in Detroit, in a column on the influence of sociodemographic status in Modern Healthcare this year.

Meeting the shared goal of reducing disparities—a priority for OMH and the nation's safety net providers—will require more resources, not less. A good starting point would be risk-adjusting the health-outcome measures used by the CMS to better account for the social factors that drive 80% of disparate health outcomes in the U.S. The result would be incentives and sanctions that reflect hospitals' quality rather than patients' communities.

Herb Kuhn

Regarding the May 16 cover story (“When the addict is a doctor,” p. 14), it's not the physician who is identified as having an addiction that's the problem, provided he is addressing his issues and can be reasonably monitored for relapse. It's the physician whose addiction is not yet discovered or who is flying under the radar that's the problem.

Random drug screenings to identify some cases of chemical dependency are entirely reasonable, in my opinion, as a condition for licensing or hospital medical staff membership.

Let's also not forget that romantic and sexual addictions are also prevalent, given that 3% to 10% of physicians have engaged in sex with a patient, according to a Vanderbilt University study. Chemical dependency and romantic/sexual boundary violations are often related.

To address these issues, patient-satisfaction surveys can incorporate questions regarding professionalism to help identify these boundary problems. Mechanisms for self-reporting also should be in place to assist the provider in addressing their issues.

Dr. James Kennedy

Smyrna, Tenn.

Regarding “Mental health advocates question Kansas 'step therapy' bill” (ModernHealthcare.com, May 16), my 28-year-old son has suffered with schizoaffective disorder for 10 years. He has said that schizophrenia is like being in a nightmare and you can't wake up.

We have lived in several states since his diagnosis. I have had to fight to get him coverage for brand-name Clozaril, the only antipsychotic that works for him, because it's expensive and the state doesn't want to pay for it. Every time he changes facilities or doctors, they put him back on the generic, Clozapine. I finally figured out what was going wrong and started advocating for him, only to be told by nursing staff that the generic “is exactly the same thing.” Clozapine does work OK for some people but not for everyone, and it is grossly unfair to deny the best medication available to people who will otherwise be forced to endure untold anguish and suffering.

If Kansas lawmakers pass the “step therapy” bill—requiring doctors to try cheaper drugs for Medicaid patients before using more expensive ones—they will be condemning their most helpless and vulnerable citizens to years of needless suffering. I invite them to visit a lockdown unit in a hospital and witness firsthand what these people go through before they cast their votes.

Julie Ash

Hulbert, Okla.