Lauren Sausser
Tue, 02 Jul 2024 09:00:00 +0000

JACKSON, Miss. — Jerrian Reedy was 9 when his father was admitted to the hospital in Hattiesburg, about two hours northeast of New Orleans, after sustaining three gunshot wounds. Reedy recalled visiting his dad in the intensive care unit that summer in 2009, even though children weren't typically permitted in that part of the hospital.

“Just seeing him laid up in bed, in a hospital bed, it was traumatizing, to say the least,” Reedy said.

His father died within a week of being admitted, in the middle of a nine-month span when Reedy also lost an aunt and a grandmother. “They say death comes in threes,” he said.

That chain of events prompted him to pursue a career in medicine, one that might help him spare other children from losing loved ones too soon.

Fifteen years later, Reedy has completed his first year at the University of Mississippi School of Medicine — a remarkable feat, and not only because his career path was born of grief and trauma. Reedy is among a small share of Black medical school students in a state where nearly 4 in 10 people — but only 1 in 10 doctors — identify as Black or African American. Of the 660 medical school students enrolled in the same four-year program as Reedy, 82 students, or about 12%, are Black.

Medical schools around the country are trying to recruit Black, Hispanic, and Native American students, all of whom remain disproportionately underrepresented in the field of medicine. Research has shown that patients of color prefer seeing doctors of their own race – and some studies have shown health outcomes are better for Black patients seeing Black doctors.

But a recent swell of Republican opposition threatens to upend those efforts, school administrators say, and could exacerbate deep health disparities already experienced by people of color.

Since 2023 — the year the Supreme Court voted to outlaw affirmative action in higher education — more than two dozen states, including Alabama, Florida, Mississippi, North Carolina, and Texas, have introduced or passed laws to restrict or ban diversity, equity, and inclusion, or DEI, programs.

“I don't expect this movement of anti-DEI legislation to slow down or stop at all,” said Anton Gunn, a health care consultant and former head of the Office of External Affairs at the U.S. Department of Health and Human Services. “And it likely will exacerbate if Donald Trump gets the opportunity to be president of the United States again.”

Diversity Programs Face Pushback

In 2023, Florida and Texas became the first states to pass laws that banned DEI efforts in higher education. Several other states, including Idaho, North Carolina, and Wyoming, passed laws targeting such programs this year.

In Mississippi, state Rep. Becky Currie and state Sen. Angela Burks Hill, both Republicans, introduced separate bills that would have restricted how colleges and universities could spend money on DEI initiatives. Both bills died in legislative committees and were not brought before the 2024 legislature for a vote.

In a statement, Hill said that Mississippi needs more doctors of all kinds, not just more Black doctors, and that she thinks money spent on DEI salaries and programs should be reallocated to initiatives benefiting all students.

“Qualifications should determine who gets into medical school not color or socioeconomic status,” she said. “Can't we just be happy with more highly qualified doctors no matter their skin color? I thought a color blind society was the goal.”

Nationally, the movement to ban DEI programs has broad conservative support.

Jay Greene, a senior research fellow at the Heritage Foundation, a conservative think tank, said he believes diversity programs “fail for a hundred reasons.” He cited research he conducted with a conservative medical advocacy group called Do No Harm refuting the premise that access to Black doctors improves health outcomes among Black patients.

“That doesn't mean there's no potential benefits for having greater diversity in the doctor workforce,” Greene said. Having more Black doctors, for example, might encourage more Black children to consider a career in health care, he said. “But that benefit is not health outcomes.”

Meanwhile, school administrators are closely watching the progress of such laws.

In March, the University of Florida eliminated all DEI programs and terminated jobs related to those efforts. In Alabama, lawyers and school leaders are grappling with a bill signed the same month by Republican Gov. Kay Ivey that bans DEI programs in public schools, state agencies, and universities starting Oct. 1.

“We have to be very, very careful,” said Richard deShazo, who teaches at the University of Alabama's Marnix E. Heersink School of Medicine in Birmingham and used to chair a committee that raised money for Black medical school students.

“You cannot raise money for Black kids. You have to raise money for medical students,” he said.

A Bitter History

A shortage of Black doctors isn't unique to Mississippi. The same story could be told in many other places, especially across the South, where more than half of all Black Americans live and where health outcomes regularly rank among the worst in the United States.

But a look at Mississippi, one of the unhealthiest states in the country, shows how the roots of systemic racism continue to shape the nation's health care workforce.

“A lot of the Black physicians in the state have a bitter taste in their mouth about our medical school,” said Demondes Haynes, associate dean of medical school admissions at the University of Mississippi Medical Center, where he graduated in 1999 as one of four Black students in his class.

An estimated 1.1 million Black people live in Mississippi, where there are fewer than 600 Black doctors. Research suggests health outcomes would improve if there were more. One study published last year in the medical journal JAMA Network Open found that life expectancy was longer among Black patients in counties with higher ratios of Black primary care physicians.

In a study based in Oakland, California, that involved more than 1,300 Black men, those who were assigned a Black doctor were more likely to agree to screening tests for diabetes, cholesterol, and other health concerns, according to the findings published in 2018 by the National Bureau of Economic Research.

“We absolutely are not saying every Black patient has to have a Black doctor,” Haynes said. But because the patient population in Mississippi is diverse, “they should at least have the right to say, ‘This is what I want,'” he added.

However, most Black patients aren't afforded that choice. Nearly two dozen of Mississippi's 82 counties have no Black doctors, while four counties claim no doctors at all, according to a physician workforce report published by the state in 2019.

For more than a century, dating to its founding in the mid-1800s, the University of Mississippi didn't admit Black students — and that policy applied to its medical school. In 1972, nearly 10 years after the Civil Rights Act of 1964 banned racial segregation in higher education, the first Black physician graduated from the medical school in Jackson. Even then, very few Black students were admitted to study medicine there each year.

Before the federal government banned the school from rejecting Black applicants because of their race, aspiring Black doctors who applied were diverted to one of the historically Black colleges and universities, or HBCUs, such as Meharry Medical College in Nashville, Haynes said.

Many older Black physicians in Mississippi still remember getting those rejection letters, he said, pointing out composite photographs of physician graduates that line the walls of the medical school building in Jackson. Many of the earliest composites, dating to the 1950s, showcase classes of all-white, and almost all-male, students.

“Mississippi history — everybody remembers it,” Haynes said. “And those people who experienced it, it's hard for them.”

‘Shaping the Possibilities'

On a damp Saturday morning in mid-April, 17-year-old Dorothy Gray, a high school junior, stepped up to a hospital bed at the medical school in Jackson to intubate a mock patient in a simulation lab.

Gray was one of more than 100 high school and college students who attended the University of Mississippi School of Medicine's annual African American Visit Day, established more than 10 years ago to foster interest among prospective Black students. The administrators, who also host special visiting days for Hispanic and Native American students, said anyone, regardless of race or ethnicity, may attend. They acknowledge that most attendees won't become doctors, and their purpose isn't to extend preferential treatment to minority applicants.

“This is about shaping the possibilities of what could be,” said Loretta Jackson-Williams, the school's vice dean for medical education. “These kids are at that precipice where they can choose to do something that's really hard for their future or they can choose an easier pathway. That choice doesn't come about overnight.”

Besides African American Visit Day, medical school leaders in Mississippi also offer a test prep program for applicants from underrepresented backgrounds who have been rejected from medical school.

The school recently identified 16 applicants, 12 of whom are Black, who were not accepted to the medical school during the last admissions cycle because their MCAT scores were too low. This year, those applicants will receive a test prep course designed by The Princeton Review — free of charge — and will have a chance to meet with administrators to learn how their medical school applications might be strengthened.

“So many students have never had someone tell them, ‘You can do this. I believe you can do this,'” said Dan Coleman, the medical school's outreach director.

For Jerrian Reedy, who wants to become an orthopedic surgeon, the path to medical school was years in the making. He took advantage of the University of Mississippi Medical Center's PROMISE program — short for Promoting Recruitment Opportunities in Medicine with Individual Study Experiences — which assures acceptance to students from disadvantaged backgrounds who meet certain eligibility requirements, including a 3.0 GPA in their undergraduate science classes.

During his sophomore year as an undergraduate, Reedy saw an opportunity to learn more about medical school when Haynes, the assistant dean, visited the Ole Miss campus in Oxford to interview students.

“I saw some open slots, put my name down,” he said. “The rest is history.”

——————————
By: Lauren Sausser
Title: Mississippi Lacks Black Doctors, Even as Lawmakers Increasingly Target Diversity Programs
Sourced From: kffhealthnews.org/news/article/black-doctor-shortage-mississippi-diversity-dei-programs/
Published Date: Tue, 02 Jul 2024 09:00:00 +0000

Stephanie Armour
Mon, 01 Jul 2024 15:30:00 +0000

A landmark Supreme Court decision that reins in federal agencies' authority is expected to hold dramatic consequences for the nation's health care system, calling into question government rules on anything from consumer protections for patients to drug safety to nursing home care.

The June 28 decision overturns a 1984 precedent that said courts should give deference to federal agencies in legal challenges over their regulatory or scientific decisions. Instead of giving priority to agencies, courts will now exercise their own independent judgment about what Congress intended when drafting a particular law.

The ruling will likely have seismic ramifications for health policy. A flood of litigation — with plaintiffs like small businesses, drugmakers, and hospitals challenging regulations they say aren't specified in the law — could leave the country with a patchwork of disparate health regulations varying by location.

Agencies such as the FDA are likely to be far more cautious in drafting regulations, Congress is expected to take more time fleshing out legislation to avoid legal challenges, and judges will be more apt to overrule current and future regulations.

Health policy leaders say patients, providers, and health systems should brace for more uncertainty and less stability in the health care system. Even routine government functions such as deciding the rate to pay doctors for treating Medicare beneficiaries could become embroiled in long legal battles that disrupt patient care or strain providers to adapt.

Groups that oppose a regulation could search for and secure partisan judges to roll back agency decision-making, said Andrew Twinamatsiko, director of the Health Policy and the Law Initiative at Georgetown University's O'Neill Institute. One example could be challenges to the FDA's approval of a medication used in abortions, which survived a Supreme Court challenge this term on a technicality.

“Judges will be more emboldened to second-guess agencies,” he said. “It's going to open agencies up to attacks.”

Regulations are effectively the technical instructions for laws written by Congress. Federal agency staffers with knowledge related to a law — say, in drugs that treat rare diseases or health care for seniors — decide how to translate Congress' words into action with input from industry, advocates, and the public.

Up until now, when agencies issued a regulation, a single rule typically applied nationwide. Following the high court ruling, however, lawsuits filed in more than one jurisdiction could result in contradictory rulings and regulatory requirements — meaning health care policies for patients, providers, or insurers could differ greatly from one area to another.

One circuit may uphold a regulation from the Centers for Disease Control and Prevention, for example, while other circuits may take different views.

“You could have eight or nine of 11 different views of the courts,” said William Buzbee, a professor at Georgetown Law.

A court in one circuit could issue a nationwide injunction to enforce its interpretation while another circuit disagrees, said Maura Monaghan, a partner at Debevoise & Plimpton. Few cases are taken up by the U.S. Supreme Court, which could leave clashing directives in place for many years.

In the immediate future, health policy leaders say agencies should brace for more litigation over controversial initiatives. A requirement that most Affordable Care Act health plans cover preventive services, for example, is already being litigated. Multiple challenges to the mandate could mean different coverage requirements for preventive care depending on where a consumer lives.

Drugmakers have sued to try to stop the Biden administration from implementing a federal law that forces makers of the most expensive drugs to negotiate prices with Medicare — a key cog in President Joe Biden's effort to lower drug prices and control health care costs.

Parts of the health care industry may take on reimbursement rates for doctors that are set by the Centers for Medicare & Medicaid Services because those specific rates aren't written into law. The agency issues rules updating payment rates in Medicare, a health insurance program for people 65 or older and younger people with disabilities. Groups representing doctors and hospitals regularly flock to Washington, D.C., to lobby against trims to their payment rates.

And providers, including those backed by deep-pocketed investors, have sued to block federal surprise-billing legislation. The No Surprises Act, which passed in 2020 and took effect for most people in 2022, aims to protect patients from unexpected, out-of-network medical bills, especially in emergencies. The high court's ruling is expected to spur more litigation over its implementation.

“This really is going to create a tectonic change in the administrative regulatory landscape,” Twinamatsiko said. “The approach since 1984 has created stability. When the FDA or CDC adopt regulations, they know those regulations will be respected. That has been taken back.”

Industry groups, including the American Hospital Association and AHIP, an insurers' trade group, declined to comment.

Agencies such as the FDA that take advantage of their regulatory authority to make specific decisions, such as the granting of exclusive marketing rights upon approval of a drug, will be vulnerable. The reason: Many of their decisions require discretion as opposed to being explicitly defined by federal law, said Joseph Ross, a professor of medicine and public health at Yale School of Medicine.

“The legislation that guides much of the work in the health space, such as FDA and CMS, is not prescriptive,” he said.

In fact, FDA Commissioner Robert Califf said in an episode of the “Healthcare Unfiltered” podcast last year that he was “very worried” about the disruption from judges overruling his agency's scientific decisions.

The high court's ruling will be especially significant for the nation's federal health agencies because their regulations are often complex, creating the opportunity for more pitched legal battles.

Challenges that may not have succeeded in courts because of the deference to agencies could now find more favorable outcomes.

“A whole host of existing regulations could be vulnerable,” said Larry Levitt, executive vice president for health policy at KFF.

Other consequences are possible. Congress may attempt to flesh out more details when drafting legislation to avoid challenges — an approach that may increase partisan standoffs and slow down an already glacial pace in passing legislation, Levitt said.

Agencies are expected to be far more cautious in writing regulations to be sure they don't go beyond the contours of the law.

The Supreme Court's 6-3 decision overturned Chevron U.S.A. v. Natural Resources Defense Council, which held that courts should generally back a federal agency's statutory interpretation as long as it was reasonable. Republicans have largely praised the new ruling as necessary for ensuring agencies don't overstep their authority, while Democrats said in the aftermath of the decision that it amounts to a judicial power grab.

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By: Stephanie Armour
Title: The Supreme Court Just Limited Federal Power. Health Care Is Feeling the Shockwaves.
Sourced From: kffhealthnews.org/news/article/supreme-court-chevron-deference-doctrine-health-care-policy-shockwaves/
Published Date: Mon, 01 Jul 2024 15:30:00 +0000

John Rossheim
Mon, 01 Jul 2024 09:00:00 +0000

“You had to pay the fee, or the doctor wasn't going to see you anymore.”

That was the takeaway for Terri Marroquin of Midland, Texas, when her longtime physician began charging a membership fee in 2019. She found out about the change when someone at the physician's front desk pointed to a posted notice.

At first, she stuck with the practice; in her area, she said, it is now tough to find a primary care doctor who doesn't charge an annual membership fee from $350 to $500.

But last year, Marroquin finally left to join a practice with no membership fee where she sees a physician assistant rather than a doctor. “I had had enough. The concierge fee kept going up, and the doctor's office kept getting nicer and nicer,” she said, referring to the décor.

With the national shortage of primary care physicians reaching 17,637 in 2023 and projected to worsen, more Americans are paying for the privilege of seeing a doctor — on top of insurance premiums that cover most services a doctor might provide or order. Many people seeking a new doctor are calling a long list of primary care practices only to be told they're not taking new patients.

“Concierge medicine potentially leads to disproportionately richer people being able to pay for the scarce resource of physician time and crowding out people who have lower incomes and are sicker,” said Adam Leive, lead author of a 2023 study on concierge medicine and researcher at University of California-Berkeley's Goldman School of Public Policy.

Leive's research showed no decrease in mortality for concierge patients compared with similar patients who saw non-concierge physicians, suggesting concierge care may not notably improve some health outcomes.

A 2005 study showed concierge physicians had smaller proportions of patients with diabetes than their non-concierge counterparts and provided care for fewer Black and Hispanic patients.

There's little reliable data available on the size of the concierge medicine market. But one market research firm projects that concierge medicine revenue will grow about 10.4% annually through 2030. About 5,000 to 7,000 physicians and practices provide concierge care in the United States, most of whom are primary care providers, according to Concierge Medicine Today. (Yes, the burgeoning field already has a trade publication.)

The concierge pitch is simple: More time with your doctor, in-person or remotely, promptly and at your convenience. With many primary care physicians caring for thousands of patients each in appointments of 15 minutes or less, some people who can afford the fee say they feel forced to pay it just to maintain adequate access to their doctor.

As primary care providers convert to concierge medicine, many patients could face the financial and health consequences of a potentially lengthy search for a new provider. With fewer physicians in non-concierge practices, the pool available to people who can't or won't pay is smaller. For them, it is harder to find a doctor.

Concierge care models vary widely, but all involve paying a periodic fee to be a patient of the practice.

These fees are generally not covered by insurance nor payable with a tax-advantaged flexible spending account or health savings account. Annual fees range from $199 for Amazon's One Medical (with a discount available for Prime members) to low four figures for companies like MDVIP and SignatureMD that partner with physicians, to $10,000 or more for top-branded practices like Massachusetts General Hospital's.

Many patients are exasperated with the prospect of pay-to-play primary care. For one thing, under the Affordable Care Act, insurers are required to cover a variety of preventive services without a patient paying out-of-pocket. “Your annual physical should be free,” said Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation. “Why are you paying $2,000 for it?”

Liz Glatzer felt her doctor in Providence, Rhode Island, was competent but didn't have time to absorb her full health history. “I had double mastectomy 25 years ago,” she said. “At my first physical, the doctor ran through my meds and whatever else, and she said, ‘Oh, you haven't had a mammogram.' I said, ‘I don't have breasts to have mammography.'”

In 2023, after repeating that same exchange during her next two physicals, Glatzer signed up to pay $1,900 a year for MDVIP, a concierge staffing service that contracts with her new doctor, who is also a friend's husband. In her first couple of visits, Glatzer's new physician took hours to get to know her, she said.

For the growing numbers of Americans who can't or won't pay when their doctor switches to concierge care, finding new primary care can mean frustration, delayed or missed tests or treatments, and fragmented health care.

“I've met so many patients who couldn't afford the concierge services and needed to look for a new primary care physician,” said Yalda Jabbarpour, director of the Robert Graham Center and a practicing family physician. Separating from a doctor who's transitioning to concierge care “breaks the continuity with the provider that we know is so important for good health outcomes,” she said.

That disruption has consequences. “People don't get the preventive services that they should, and they use more expensive and inefficient avenues for care that could have otherwise been provided by their doctor,” said Abbie Leibowitz, chief medical officer at Health Advocate, a company that helps patients find care and resolve insurance issues.

What happens to patients who find themselves at loose ends when a physician transitions to concierge practice?

Patients who lose their doctors often give up on having an ongoing relationship with a primary care clinician. They may rely solely on a pharmacy-based clinic or urgent care center or even a hospital emergency department for primary care.

Some concierge providers say they are responding to concerns about access and equity by allowing patients to opt out of concierge care but stay with the practice group at a lower tier of service. This might entail longer waits for shorter appointments, fewer visits with a physician, and more visits with midlevel providers, for example.

Deb Gordon of Cambridge, Massachusetts, said she is searching for a new primary care doctor after hers switched to concierge medicine — a challenge that involves finding someone in her network who has admitting privileges at her preferred hospitals and is accepting new patients.

Gordon, who is co-director of the Alliance of Professional Health Advocates, which provides support services to patient advocates, said the practice that her doctor left has not assigned her a new provider, and her health plan said it was OK if she went without one. “I was shocked that they literally said, ‘You can go to urgent care,'” she said.

Some patients find themselves turning to physician assistants and other midlevel providers. But those clinicians have much less training than physicians with board certification in family medicine or internal medicine and so may not be fully qualified to treat patients with complex health problems. “The expertise of physician assistants and nurse practitioners can really vary widely,” said Russell Phillips, director of the Harvard Medical School Center for Primary Care.

——————————
By: John Rossheim
Title: The Concierge Catch: Better Access for a Few Patients Disrupts Care for Many
Sourced From: kffhealthnews.org/news/article/concierge-medicine-primary-care-doctor-pay-to-play/
Published Date: Mon, 01 Jul 2024 09:00:00 +0000

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