Voice: Dr. Ashish Jha

Dr. Ashish Jha is a professor of health policy and management at the Harvard School of Public Health and has done extensive research on the role of public policy in the health-care delivery system, particularly as it relates to quality and costs and how it affects minority and economically disadvantaged people.

“These gaps took, in some cases, centuries to develop. I am sure if you go back to the 19th Century, the quality of care that minorities got was much worse than where it is now. So the gaps have been there a long time. It’s not going to be fixed overnight. I think we just want to just be thoughtful about our policies to make sure they don’t make things worse. And that it will take a long time.”

Health disparities, a look at sort of population-level outcomes, obviously a lot of things go into it. Education. The sort of job opportunities. Communities and neighborhoods. All of those things affect sort of people’s overall health. But another important contributor is healthcare – what the quality of healthcare is that you have access to and that you end up using.

Dr. Ashish Jha

Dr. Ashish Jha

And so my interest – one of my interests – has been focusing on the providers that disproportionately care for minority and poor patients, and trying to better understand who they are, what their struggles are, how good they are, and, ultimately, with the goal of trying to figure out how do we get them to improve and get better.
And what we have found on a national level time and time again in a variety of different studies is that — and you could argue it’s not totally surprising – that providers that disproportionately care for poor patients, and also those that disproportionately care for minorities, even when you take sort of socio-economics into account, tend to be lower quality, they tend to have worse outcomes. They tend to basically be, just, not as focused on quality of care as other institutions. And to me that has struck me as a place where there are some real things we can do to make care better.

One of the things we don’t always know, we don’t really understand very well, is why is it that minority patients tend to cluster in these institutions. It’s not the sort of simple answer of, well, it’s just about where they live. Because what we have seen from our study as well as others is that minority patients, for instance, will often bypass a hospital that’s pretty good to go to a hospital that might even be farther away but not as good. So it’s not an issue of everybody goes to the closest hospital and minority patients always end up at worse ones. And I think the reasons why people cluster at certain hospitals is there’s historical reasons, you know, there are institutions that have a long history of caring for minority patients. I’ve talked to patients in the past who literally will say to me, you know, I always go to this medical center because that’s where black patients go. And it’s a very odd thing to hear from a patient, saying that’s where patients like me go. My point is this stuff is complex, and there’s a historical basis for this.

Personally, I would like to see a country that is sort of less segregated and more integrated, but also at the same time, to the extent that we have what we have, I think what we need to do is adopt a strategy that helps these institutions improve. And there’s actually a lot we can do. I think some of the work we have done in the past suggests that one place to focus is sort of leadership, and training of leadership in these organizations. A lot of minority-serving hospitals have senior leaders, board members, just not as experienced in quality, not giving quality as much of a priority. It seems to me that’s where there’s a lot of opportunity for improvement, and target real educational interventions, and accountability for these institutions. You don’t get to provide lower quality care just because your patients are poor or minorities.

You know, what’s interesting is if you look at the Affordable Care Act, there is, I think, both good news and bad news for these institutions. I mean the good news is a lot of these institutions take care of a lot of uninsured patients, and it’s obvious, to the extent that we have fewer uninsured patients, that is going to help. And the other part of the Affordable Care Act that I like is in general it tries to move the healthcare system towards greater accountability for quality and cost. The problem – the bad news – is a lot of the measures and metrics that the Affordable Care Act is focusing on are such that they’re really going to disproportionately hurt these institutions. For instance, the biggest penalty for hospitals is around re-admissions. There are many reasons why patients are re-admitted. One is did you get good discharge coordination when you were leaving the hospital. But probably the single biggest reason why people get re-admitted has to do with their socio-economic status, what’s going on at home, community resources. And this is why we see institutions that care for poor patients have dramatically higher readmission rates. And so what’s going to happen, and we’ve seen this in a bunch of other parts of the ACA provisions as well, is that a lot of what’s going to happen for the hospital side at least is serious penalties for institutions that take care of poor and minority patients. And so the people who focus on the safety net are worried that the ACA, out of desire to build more accountability into the system, has set it up so they’re basically going to end up punishing the safety net institutions.

The thing that makes me hopeful over the longer run is that until now – I keep using this word, but I’ll say it again – there has been very little accountability. And what I mean by that, by the way, is, you know, right now you could go to a hospital, and as long as it’s accredited and sort of meets some very basic level of standards, no one is going to really pay close attention to how good that care is. And what that means, and we see this over and over again, is there are these huge variations in quality and cost, and there are hospitals where mortality rates are three times higher than you would expect them to be, and really no one is paying attention. I think the broader trend in the healthcare market is for more accountability, for more data, for more transparency. And as much as I do think if we don’t do a good job of it there is a short term risk for safety net institutions, over the long run, I think this trend is helpful, because it means that everybody has a better chance of getting high quality care. It also means that for minority and poor patients who are often at risk for the low quality care, that they’re going to have more opportunities to figure out where to go. So, in general, looking forward I’m pretty optimistic but I think there’s going to be some bumps in the short run.

So, let me be very clear about what I think can be done in a decade: I think on the quality and making sure that the health care system has eliminated disparities – yes. Do I think social disparities and overall health disparities can be done? That’s a much taller order, right, because then you’re talking about schools, you’re trying to fix communities and neighborhoods, and I have to tell you that my expertise on how you fix neighborhoods and schools is no greater than anybody else’s. It’s hard for me to know. I’m thinking more on the healthcare system, it can be done within a decade – if we make it a real priority.

These gaps took, in some cases, centuries to develop. I am sure if you go back to the 19th Century, the quality of care that minorities got was much worse than where it is now. So the gaps have been there a long time. It’s not going to be fixed overnight. I think we just want to just be thoughtful about our policies to make sure they don’t make things worse. And that it will take a long time. But my feeling is it doesn’t have to take another century to fix it. It’s probably a five- to ten-year process, but I want to see real movement every year going forward.

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