Of course “avoidable” is not the same as “easily avoidable,” and we need to systematically consider the barriers to equity in healthcare. Some disparities in disease are genetic and may truly be unavoidable. Others are rooted in deep-seated social problems that lead to economic and educational shortfalls. But what about the barriers that our healthcare system itself has created? Let me give some examples.
We have an opportunity to take a stand this year on the need for adequate racial diversity in rheumatology, and, more importantly, to take action.
Challenges for Rheumatologists and Patients
An ACR member recently told me of her concern about the restrictions on access to outpatient care that have been imposed by a renowned—and wealthy—academic medical center in New York on patients who live in their immediate vicinity, but whose insurance coverage is suboptimal. After caring for a hospitalized scleroderma patient, this rheumatologist was informed that her patient, who is African American, would be permitted to return for only one follow-up visit in her clinic, but after that could instead be sent to another hospital’s outpatient clinic that was far enough away to be difficult for this patient to access, but was willing to accept her insurance coverage.
This vignette, which is far from unique, exemplifies the extent to which many—maybe most—of our elite academic health centers have transformed themselves from social institutions that once fostered medicine as a profession into businesses that are thinly—and falsely—disguised as nonprofit entities. The rheumatologist in this case is trapped in an irreconcilable conflict between her duty to her patient and the constraints imposed by her provider. In the process, she has morphed from a physician who practices a profession to a “healthcare provider,” an agent of a “health system.” The consequence is fragmented medical care and disparities in disease outcomes.
At the same time, it would be a mistake to ignore the tremendous economic pressures faced by many rheumatologists, especially those engaged in solo practice who are beleaguered by denials of payment for their services, pre-authorizations for not only biologics but also methotrexate and prednisone, rising costs, and Medicare fee scales that have been declining in relation to practice expenses. In order to survive, some practices have had to cap the percentage of patients under their care whose insurance coverage is poor. This compromises access to healthcare and undoubtedly creates disparities in outcome, but is preferable to the alternative of rheumatologists being forced to close their practices. At the same time, when our larger and more successful practices and—especially—our wealthiest academic centers (that spend millions of dollars on advertising) engage in patient cherry-picking, we had better take a long, hard look in the mirror.
What Can We Do?
Another barrier to equitable care for patients with rheumatic diseases may lie within the workforce composition of our specialty. Recently, the ACR’s Young Investigator Subcommittee, led by John Fitzgerald, MD, PhD, surveyed rheumatology fellows’ perceptions about training and careers in academia. The interesting report of this survey is currently being prepared for publication, but I want to point out the demographic composition of the rheumatology fellows who responded to the survey: 57% female but only 2% African American! And this 2% figure is not just the proportion among current fellows—a quick glance around the room at any ACR meeting quickly reveals that this figure reflects the composition of our specialty, within which African Americans are more poorly represented than in most other fields of medicine.
