For 110 years, the National Medical Association [NMA] has been an unwavering voice for parity in the delivery of health care in the United States. As we all know, the struggle for parity continues, and more and more Americans are becoming engaged in the discussion.

The current debate about disparities in health care seems to pivot around the following: are disparities in care dependent on who people are [race and ethnicity], or where people go to get their care [access and quality]?

The framing of that question concerns us greatly for one simple reason. Disparities in health care are unacceptable no matter what the causes. Receiving the highest quality care when you reside in the world’s leading healthcare innovator should, therefore, become the ‘coin of the realm’, no matter who you are, or where you go to receive care.
Simply put - society loses too much when some are more equal than others.

The NMA remains committed to doing whatever we can, strategically and tactically, to bring about lasting system change in the access to and delivery of the highest quality care to all Americans. Given that the patients served by our membership are among the most vulnerable, we will continue to pay close attention to the issues affecting their welfare.

The following is a summation of the most pressing of these issues. Please stay tuned to the site for periodic updates.

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Widespread Adoption and Meaningful Use of Health Information Technology

The widespread adoption and “meaningful use” of health information technology (HIT) will be a useful tool, given that it would impact, among other things: data collection; record keeping; care coordination; comparative effectiveness; public health surveillance; and the evaluation of practice and utilization patterns.

To ensure that HIT does not become a blunt instrument in the hands of untrained healthcare providers and regulators, NMA recommends:

The discussion about standards, certification, and interoperability must be as robust as possible.

Transparency will ensure buy-in and ownership.

Clinical data are probably more reliable predictors of quality improvement than are claims data.

Providers in smaller practice settings need more help with adopting HIT.

HIT implementation will be an ultimate failure if it does not contribute to the reduction of disparities and inequities in care delivery.

“Meaningful use” will not mean the same thing for all users, and definitions may change over time, given the realities on the ground. The system will discern how meaningful the use by the results produced. For practical purposes, the NMA suggests meaningful use of HIT should accomplish some or all of the following:

Enhance data collection across all relevant categories;
Expedite information exchange;
Reduce medical errors;
Improve coordination of care;
Increase patient engagement;
Improve health outcomes;
Reduce costs.

The Office of the National Coordinator’s role as facilitator of this conversation should remain sacrosanct.

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Comparative Effectiveness Research (CER)

Comparative Effectiveness Research (CER) offers great promise in the quest for determining value, and subsequently rewarding therapies, systems, and practitioners that deliver the most favorable health outcomes. As with all cutting edge ideas however, there are dangers associated with the obvious opportunity CER represents.

The NMA recommend therefore:

CER should proceed with all deliberate speed.

CER should be patient-centric.

The proposed Center for Comparative Effectiveness Research should be housed outside the Federal government.

CER should account for population and sub-population differences.

The CER process should be transparent and collaborative.

Collecting the data that will inform CER is only as effective as the Health IT (HIT) infrastructure that supports the research.

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Data Collection

Another critical recommendation of Unequal Treatment was the collection of relevant demographic data, which data would define which health metrics show an upward trend among minority patients from year to year. There remains an overwhelming need for uniform methods for collecting these various categories of health care data. Health IT can play a vital role here.

There is also a corresponding need for these data to mean the same thing across scientific disciplines, and to mean the same thing from state to state, and from region to region.

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Universal Health Insurance Coverage

In its landmark report entitled Insuring America’s Health released in 2004, the IOM concluded: 

Health care coverage should be universal.  Everyone living in the United States should be covered by health insurance.  Being uninsured can damage the health of individuals and families.  Uninsured children and adults use medical and dental services less often than insured people and are less likely to receive routine preventive care (Newacheck et al., 1998b: McCormick et al., 2001: IOM, 2002b).

Previous research on the subject has also revealed the following: They [the uninsured] are also less likely to have a regular source of care than are insured people (Zuvekas and Weinick, 199; Weinick et al., 2000).

Insuring America’s Health concludes by recommending that the following four components must characterize extension of health insurance coverage, including: 
Health care coverage should be continuous.
Health care coverage should be affordable to individuals and families.
The health insurance strategy should be affordable and sustainable for society.
Health insurance should enhance health and well being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable. 

The NMA embraces all of these principles. In our view, the moral imperative to insure the uninsured [47 million and counting] has never been more urgent.

We are mindful of cost considerations of early detection and preventive care, but we are not deterred from our conviction that universal healthcare coverage for all Americans is a goal worth pursuing.

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Increasing the Number of Minority Health Professionals

One of the most important conclusions of Unequal Treatment is that there is a need for more “culturally competent” health professionals. The more minorities recruited into the health professions, the greater the chances of serving more patients in minority groups; which is where the Federal government can and should play a vital facilitating role. The NMA is convinced that “pipeline” programs aimed at producing significantly more physicians and other providers from minority groups must have the full financial commitment of the Federal government.

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Preserving the Health Care Safety Net

As the “Conscience of American Medicine”, the NMA is very concerned about the preservation of the health care safety net. The services provided by the nation’s Medicaid program makes available a significant part of this safety net, the stewardship of which the NMA believes is a national responsibility.

Budget crises in many states are having devastating effects on Medicaid beneficiaries that are from minority communities. In states with substantial rural populations, this problem is even more acute. Sustaining the viability of Medicaid should therefore become an even more important priority, since Medicaid also pays for the lion’s share of the long-term care available in America’s health care system.

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Eliminating Health Care Disparities

Ultimately, this issue impacts and is impacted by all the issues we will list behind it, and should therefore be considered an umbrella issue.

The NMA takes the position that any solution-oriented national health policy to eliminate [or at least reduce] disparities must, at a minimum, address the following basic questions:

Can African Americans and other underserved minorities find and have real access to equal high quality health care when they need it?
Will physicians of African descent and other ethnic and minority groups be available to provide high quality health care to their communities?
How will America’s health care infrastructure support and foster improvement of the health status of African Americans and other underserved minorities? 
What primary issues must be addressed to ensure that America’s health care delivery system provides the highest quality health care to all its citizens?

In the past, we have taken positions on various strategies and programs for accomplishing the aforementioned. We remain committed to the recommendations of the landmark 2002 Institute of Medicine (IOM) report, Unequal Treatment.

This report, among other salient conclusions, echoed (with data) the NMA’s century-old message that the unintended consequences of racism persist in the delivery of health care in America. This message has been reinforced by the 2008 National Health Disparities Report [a key recommendation of Unequal Treatment], which is now the premier annual report card that tracks how well we are doing with reducing disparities.

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Medicare Reimbursements

The Sustainable Growth Rate (SGR) is part of a complex economic formula for determining how much America’s doctors get paid for serving Medicare patients. The problem with the formula is that it fluctuates based on factors that have little to do with the true cost or quality of care delivered, or, more importantly, the health outcomes resulting from said delivery.

With the escalating cost of providing medical care, negative updates in Medicare payment rates are simply untenable. That scenario simply places Medicare recipients at greater health risk for negative health outcomes because it fosters more physicians having to make the choice to “opt out” of the Medicare system. This is a vulnerable segment of our population [the elderly and disabled], and we must do all we can to improve the quality of their health care.

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Pay for Performance

Pay for Performance White Paper from NMA Task Force May 2007

A growing number of thought leaders in our nation are now advocating the concept known as ‘pay-for-performance’. As the moniker implies, ‘performers’ will be paid, and others may not. The question though is whether this incentive-based mechanism will improve the quality of care delivered. Or, more importantly, will this approach improve health outcomes for our patients?

The platform for setting these standards is evidence-based. We remain concerned that the ‘evidence base’ will be developed among populations whose clinical characteristics are not representative of the populations served by the membership of the NMA. America’s most vulnerable will thus be written out of the script before the first curtain call. The NMA continues to negotiate the suggested processes for determining these standards.

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Medical Liability and Malpractice Insurance

NMA recognizes that injured parties do need a mechanism by which they can seek justice to redress medical negligence, but frivolous lawsuits and skyrocketing malpractice insurance premiums are driving America’s physicians out of business. In the minority community this is likely to translate into an exacerbation of healthcare disparities.

The result is that some doctors are opting to retire earlier than they would otherwise have. Others are scaling down their practices (some obstetricians refusing to deliver babies for example, given that they are now forced to pay over $100,000 a year for malpractice coverage in several markets). More commonly, doctors are relocating to states where they can afford their liability coverage.

Not enough physicians translates to the stark reality that sick people in vulnerable communities are going without care, further exacerbating the disparity situation with which we are so concerned.  The NMA strongly advocates the enactment of federal legislation that offers common sense solutions that are equitable for all concerned.

Such solutions should include, among others:

‘caps’ on non-economic damages in malpractice litigation
reforming the process by which insurance companies set the premiums paid for malpractice insurance coverage
a careful consideration of medical courts as a viable alternative to the tort system.

A legislative response is desperately needed at the federal level. Unless we, as a nation, achieve a workable solution to resolve this dilemma, the hemorrhage of doctors leaving the practice of medicine will continue to drain the lifeblood out of our health care system.

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Biological Hazards and National Security

Minority communities tend to work in those sectors of the economy that increase their exposure in the event of a bio-terrorist attack. The health literacy and health communication challenges that exist in minority communities are likely to impede effective responses to such an event. Consequently, special attention must be given to ensuring that communications networks prepare health materials and instructions that are written in clear and understandable language.

The threat of pandemic influenza highlights the urgency of this outreach. Most recently, swine flu, which has now proved fatal in multiple countries, has demonstrated the need for a national commitment as well as international collaboration. We commend the White House on the steps that have been taken thus far to ensure optimal preparedness here in the United States.

Given the historical suspicion in minority communities of public health initiatives however, it is essential to have the appropriate buy-in and cooperation of minority populations in the event of a life-threatening biohazard or bio-terrorist event.

In order to establish that level of trust (preferably prior to any catastrophic event) it is imperative that ongoing education, sensitization, and positive reinforcement programs be established. 

NMA takes the position that the nation should educate physicians and other health care providers who serve minority communities as part of our nation’s preparedness efforts.

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Healthy People 2010

NMA strongly urges redirecting the nation’s attention to Healthy People 2010, as we prepare for Healthy People 2020.

Healthy People 2010 is grounded in science, built through public consensus, and designed to measure progress. It was designed to serve as a roadmap for improving the health of all people in the United States, and builds on successful initiatives pursued over the last two decades prior to its adoption.

Healthy People 2010 had two major goals:  to increase quality and years of healthy life, and to eliminate health disparities. In order to achieve these laudable goals, the Surgeon General identified several focus areas from which key objectives and health determinants were derived. These focus areas included: access to quality health services, and the disease areas of cancer, chronic kidney disease, diabetes, and HIV/AIDS.