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Bias in Medicine – An Untreated Epidemic

Bias – noun – prejudice in favor of or against one thing, person, or group compared with another, usually in a way considered to be unfair.

Humans are, by nature, biased in favor of their own group – village, country, race, social status – over “others” from outside that group. This tendency toward bias against those different from us is rooted in how humans process the information they get from their surroundings – “is that friend or foe?” is a pretty basic processing form. If someone looks, talks, or smells “different,” the most basic parts of the human brain can start firing warnings about stranger danger. That’s called a cognitive filter, or cognitive distortion [1].

How does this impact medicine? Since medicine is a human endeavor, everyone involved is bringing their own implicit biases [2] into the room with them. It’s human to feel a little uncomfortable with someone who looks, or acts differently than you. However, in a medical setting, what happens when a clinician “others” a patient? Or when a patient does the same thing to a clinician? My educated guess is that this drives down positive health outcomes, creating burnout in clinical staff and hampering recovery in patients.

I’m not the only one asking questions about bias in medicine. My fellow funny person (I am, after all, the “comedy health analyst [3]”) John Oliver devoted most of a recent episode of his HBO series “Last Week Tonight” to the topic [4], which I’d say is required viewing for anyone interested in this segment of health policy. In the piece, Oliver and his crew stack up some serious evidence of racial and gender bias in medicine, particularly in the cases of women having heart attacks [5], and women of color giving birth [6].

How should we – all of us, patients and the clinicians who prove our medical care – address this issue? A good first step would be to recognize that we’re all a bit racist [7] (link is to a Psychology Today article with that very title), which would at least put us in a frame of mind to question our assumptions about the person in front of us in the clinic, or the exam room, or the hospital bed – whichever side of the stethoscope we’re on.

If you’re willing to take that first step, your next step could include taking any of the Teaching Tolerance Project Implicit [8] self-tests on bias with regard to gender or race.

“I wouldn’t have seen it if I hadn’t believed it” is a quote often attributed to Canadian philosopher Marshall McLuhan [9] – a perceptive twist on the “seeing is believing” aphorism, one that asks us to challenge our assumptions about the people we encounter in our daily lives, in medicine and beyond.

Self-awareness leads to a better understanding of others. Better understanding of others leads to less distrust, and more cooperation between individual humans, and among the groups we gather in. Which just might improve human health overall. Let’s test that theory, shall we?


Resource Links

[1] cognitive filter, or cognitive distortion

[2] implicit biases

[3] comedy health analyst

[4] devoted most of a recent episode of his HBO series “Last Week Tonight” to the topic

[5] women having heart attacks

[6] women of color giving birth

[7] we’re all a bit racist

[8] Teaching Tolerance Project Implicit

[9] Canadian philosopher Marshall McLuhan

The Biggest Question No One Is Asking in Healthcare

There is a really big question in healthcare, one that could shift the entire industry toward more patient-focused care while simultaneously driving down healthcare costs. Very few people even think about this question. In my experience even fewer, if any, of those who do ask it are involved in developing healthcare policy at the federal or state level.

This one question, if deployed, would start to solve the issues facing patients, clinicians, payers, hospitals – everyone involved in getting or receiving medical care.

What’s the question?

“How much is that?”

There are two things in play in the healthcare industry that fly in the face of marketplace sense. First is the lack of price transparency. Imagine going to the grocery store and seeing aisles upon aisles of food … without any prices posted.

“How much is that package of chicken breasts?” “That depends. How are you paying for it?”

My guess is that you wouldn’t shop in that store again. Healthcare is the only consumer-facing industry in the US that doesn’t have price transparency. Worse, if you ask for pricing, you’re often met with blank stares and “I have no idea” or, worse, “we can’t tell you because [insert name of health insurer here] considers that to be proprietary business information.”

Second is how the prices are set. You’ve heard of the medical billing codes – the Holy Codes that outline Medicaid, Medicare, and health insurance reimbursement payments for everything from lab tests to joint replacement. The price values for each of those billing codes is set by an American Medical Association (AMA) committee called the RUC: the Specialty Society Relative Value Scale Update Committee (for my personal take on the RUC, see this piece). The RUC meets behind closed doors, creates the pricing list for every single medical procedure and billing code, and then publishes it. This is not price fixing, since they hand the list to the Centers for Medicare and Medicaid Services (CMS) for publication, the AMA does not publish the list on its own.

Here’s a critical health policy issue: creating price transparency. One starting point could be requiring providers to know, and share, the cost of the services they provide to the customers they serve: THE PATIENTS. On the employer sponsored insurance (ESI) front, employers are starting to push for this with reference-based pricing in their benefits packages. On the state and federal policy front, there are a rising number of discussions about all-payer claims databases (APCDs) – for a really good explainer on that, I’ll point you toward this piece from July 2018 on the Health Affairs blog, “Transparency In Health Care: Where We Stand And What Policy Makers Can Do Now.” Both of these, either in tandem or singly, might accomplish what all the healthcare blue-ribbon committees and working groups in DC haven’t been able to pull off since the 1960s: downward pressure on healthcare costs.

In 2003, the late Princeton economist Uwe Reinhardt published an article in Health Affairs titled, “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries.” Fifteen years later (on March 13, 2018 to be exact), WBUR in Boston published “Why Are U.S. Health Costs The World’s Highest? Study Affirms ‘It’s The Prices, Stupid’” – we haven’t made much progress since 2003.

Think about that as you evaluate your choices in the voting booth on November 6, and hold your representatives at the state and federal level to account after they take office. Whether you love the Affordable Care Act or not, you know that the healthcare system in the US must change, for the health of our families and communities as well as the financial health of our national economy.

And the next time you’re buying healthcare services, ask that really important question: “How much is that?” If you don’t get an answer, consider shopping in another healthcare store.

That could start bending the cost curve.