How Racial Bias Impacts Health Outcomes

COVID-19 is killing black Americans at three times the rate of white Americans. But it is not just COVID-19. Four hundred years of systematic discrimination has created systems that leave black people with dramatically worse health outcomes than others. Many living with diabetes have faced discrimination in their lifetime. Diabetes still poses barriers to getting fair treatment in our society, whether in school or work, exclusion from sports teams, or mismanagement in the hospital setting. All too often, living with diabetes as a person of color will compound these barriers.

Studies have shown that there are systemic, negative biases against people of color embedded in our healthcare system. This is layered on top of inequitable social determinants of health that people of color face, leading to poorer health outcomes, additional complications, and earlier deaths.

Black People Have a Higher Rate of Diabetes

Black people are more likely to have diabetes. There are 4.9 million non-Hispanic African Americans aged 20 years or older who have diabetes in the United States, according to the CDC. They are 77% more likely to have diabetes than non-Hispanic Caucasians. Part of this trend may be genetic, but one’s environment and socioeconomic status play a significant role in the development of type 2 diabetes, especially in a society without a robust social safety net.  Among racial and ethnic groups, African Americans have the highest poverty rate at 27.4% (compared to Hispanics at 26.6% and whites at 9.9%). Additionally, 45.8% of young black children under the age of 6 live in poverty, compared to 14.5% of white children.

There are many factors that contribute to this, but a history of institutionalized racism (the legacy of slavery, redlining and Jim Crow laws) have largely prevented African Americans from cultivating intergenerational wealth (which for most Americans comes from buying and selling real estate), and breaking the cycle of poverty proves to be nearly impossible in most circumstances.

Poorer, segregated (de facto segregation) black neighborhoods are more likely to face food deserts (areas where there are few or no grocery stores), lack access to healthy foods (including fresh fruits and vegetables), families may lack access to reliable meals (especially in the summer, when schools are no longer serving children breakfast and lunch), and unsafe streets and a lack of green space (few or no public parks). Neighborhoods of lower socioeconomic status are all risk factors for obesity and the eventual development of type 2 diabetes. 

Black People Have Higher Rates of Complications and Death

Black children and families are more likely to develop diabetes, and when they do, they face graver health outcomes. One recent study found that black youth have an average HbA1c of 10.6% compared to 8.3% for their white peers, and black children are twice as likely as white children to die from diabetes. Blacks are also more likely to experience greater disability from diabetes complications such as amputations, blindness, kidney failure, and increased risk of heart disease and stroke. Diabetic retinopathy is 46% more prevalent in African Americans than non-Hispanic whites, and African Americans are at least 2.6 times more likely to have end-stage renal disease due to diabetes than Caucasians. Most telling: the premature death rates for blacks with diabetes are 27% higher than for whites with diabetes.

racism and diabetes

Photo credit: iStock

Racism Is Built into Our Healthcare System

Implicit bias plays a large role in the unfair treatment of black people in the health care setting. In 2005, the National Academy of Medicine released a study that found that “racial and ethnic minorities receive lower-quality health care than white people, even when insurance status, income, age, and severity of conditions are comparable.” This suggests that poverty and lower socioeconomic status does not account for the whole picture of poorer health outcomes in black people with diabetes.

The report continued, “…minority persons are less likely than white persons to be given appropriate cardiac care, to receive kidney dialysis or transplants, and to receive the best treatments for stroke, cancer, or AIDS. It concluded, “some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care.” Simply put: people are dying at higher rates just because the color of their skin is darker.

One study of 400 hospitals in the United States showed that black patients with heart disease received older, cheaper, and more conservative treatments than white patients presenting with the same disease and symptoms. Black patients with diabetes have higher rates of amputations than white patients, even when less invasive interventions are available. Additionally, another study showed that physicians were more likely to prescribe pain medications to white patients, mistakenly believing that black people “feel less pain”.

COVID-19 is killing black Americans at three times the rate of white Americans.

Where Do We Go from Here?

Social determinants of health, physician and healthcare workers’ implicit bias and systemic racism in our healthcare system all contribute to higher rates of disease, complications, and death. Neighborhoods and schools remain dramatically segregated and unequally funded.

The United States has a two-tiered health care system that provides fantastic care to those who can afford private health insurance, and little to none to those who cannot (aside from Emergency Department visits). We, as a society, do not value or fund preventive health care as much as we should. We don’t prioritize feeding our babies healthy food, or making sure they have space and safety to exercise regularly. We step in with too little too late for those who need help the most. We are biased in our healthcare decisions and have not fought against institutionalized racism early or long or loud enough. Now is not the time to “not be racist”, but to actively dismantle institutionalized racism from the inside out.

We need more black physicians, and nurses, and emergency medical technicians. We need to put our dollars into segregated neighborhoods and schools and prevent diabetes before it devastates underserved communities even more. We need to listen to black patients in hospitals. We need to trust black people when they voice their health concerns. We need more black voices in the diabetes online community. We need to lift up the voices of black people.

We need to do more for those that we have failed for far too long. We have already lost so much, and we need to act before it is too late.

Source: diabetesdaily.com

Centralized Healthcare: Is It Best for the Patient?

There are many ways that a healthcare system can operate. The type of system that is best suited for a population may be dependent on many factors, including the population size, demographics, and various other economic, political and cultural considerations as well. 

Here we discuss some potential approaches to healthcare system organization and major considerations in health care reform. In large, because healthcare is a service that is paid for, the specific payment model represents a large consideration in the way the system works. Another big consideration is whether the services are paid for publicly or through private enterprises (like private insurance companies). Additional “middle-men”, such as pharmacy benefit managers (PBMs), health insurance companies, supply manufacturers and distributors, etc. can further complicate both price-setting, health care delivery, and patient outcomes. 

Many different countries have elected vastly different ways to govern health care. Some, like the UK, rely on a more centralized (public) model to deliver care and services, whereas others, like the US have historically relied more on privately funded providers and health services. In many cases, specialized entitlement programs (like Medicare and Medicaid) that are subsidized by the US Government can help specific patient populations gain access to the services they need at an affordable price. Also, although there are federal guidelines, in the US, states can also enact specific legislation to help people living in their state, by having specific state-run programs for the retired and low-income, as well as policy changes, like co-payment caps on state-regulated health plans for prescription medications like insulin. 

To Centralize… Or Not?

Some hail the benefits of a centralized, one-for-all, affordable, publicly-funded health care system (also referred to as a single payer system). After all, affordable and quality health services are a cornerstone of our well-being as a society. One of the biggest concerns brought about by critics is the lack of competition this could create, resulting in potentially fewer available resources (e.g., providers, supplies, services) and poorer quality of care as a result. In addition, this can also translate to longer wait times to receive health care services. 

As many individuals continue to struggle to afford health care in the US and other parts of the world, more people are pushing for a more comprehensive, centralized public health care system that could provide affordable services to more people. 

Current Payment Models Shape Outcomes

A large factor within a healthcare system is what the payment model to the providers looks like. An expert summary by the MMA Work Group to Advance Health Care Reform explains that there are several main models, each with its potential pros and cons. 

The fee-for-service payment system is one where reimbursement to the providers corresponds directly to the specific services rendered. This is the primary model that is used in healthcare models in the US. One major problem with this system is that getting reimbursement for each service or treatment can create a conflict of interest for providers, resulting in the potential to overtreat patients, losing focus on patient wellbeing, including preventative strategies. Also, this may limit comprehensive care for patients, as different providers may be less likely to coordinate care. On the other hand, this model can encourage productivity. It also offers a relatively direct way of reimbursement for various services. 

On the opposite side of the spectrum, capitation, refers to a carefully managed coordination of reimbursement for services. American College of Physicians explains:

Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. The actual amount of money paid is determined by the ranges of services that are provided, the number of patients involved, and the period of time during which the services are provided. Capitation rates are developed using local costs and average utilization of services and therefore can vary from one region of the country to another. In many plans, a risk pool is established as a percentage of the capitation payment. Money in this risk pool is withheld from the physician until the end of the fiscal year. If the health plan does well financially, the money is paid to the physician; if the health plan does poorly, the money is kept to pay the deficit expenses.”

This type of model may allow for more flexibility with respect to care delivery, including potentially more innovative and effective services. It may also allow for more collaboration between providers and benefit patients due to potentially shifting more focus to eliciting overall well-being as a goal. On the other hand, setting up this type of system is a complicated and arduous process, and may also limit access for high-risk patients, and possibly reduce patient options, including the providers and services available to them. 

There are multiple variations of coordinated payments within this broad spectrum, and more proposals are continuously being drawn up by various organizations. Some examples include pay-for-coordination, pay for performance, bundled payments, and various forms of comprehensive care.

Importantly experts warn of the potential effects of these systems on patients, as illustrated below –

Opinions Vary

What kind of system will work best to serve the public in a timely manner without sacrificing quality, while also being affordable? The verdict is still out, and there will likely never be a consensus. Lessons learned from different countries, and on a more local level, will likely continue to shape the dialogue and direct (typically slow-moving) policy changes. 

Some feel strongly that universal healthcare is a right, and not a privilege. Others worry that such a system will decrease the quality of services, increase wait times, and thus negatively affect the patients and their health outcomes. Some believe there is no one-size-fits-all, and that specific systems must be driven from the ground up at a very local level. 

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What do you think? How is healthcare organized where you live and do you think it is an effective model? How do you think policy has affected your diabetes-related care? How do we go about effecting significant policy changes, when and where they’re needed?  

Source: diabetesdaily.com

Prior Authorization: Getting Diabetes Supplies and Medications Covered by Insurance

This content originally appeared on diaTribe. Republished with permission.

By Divya Gopisetty

What is a prior authorization? Read on to learn more about why diabetes supplies or medications might require a prior authorization and how to go through the process

It can be frustrating to learn that you need a prior authorization when you already have a prescription. Insurance plans sometimes require a prior authorization to cover a diabetes supply, device, or medication, even if your doctor prescribed it to you.

Read on to learn about what a prior authorization is, and how you can make the submission process as smooth as possible.

In this article:

Click to jump to a specific section!

What is a prior authorization?

My pharmacist told me I need a prior authorization. What happens next?

How can I check if I need a prior authorization?

How long do prior authorizations last?

What happens if the prior authorization is denied?

What is a prior authorization?

A prior authorization, also known as a pre-authorization or pre-certification, means that your healthcare provider or device company has to get specific approval from your health insurance company (so that it will pay for it).  The requirements for prior authorization differ between and within insurance plans.

If you need a prior authorization, the pharmacist cannot process your prescription until your healthcare professional has contacted the insurance company. Similarly, a device company may not ship your diabetes device to you until it has prior authorization from the insurance company.

A prior authorization is designed to make sure certain prescription drugs or devices are used correctly and only when medically necessary. Before your insurance plan will cover a certain device or drug, you must show that you meet a set of criteria.

Prior authorizations are most often handled by your healthcare professional’s office, but sometimes are handled by the device company itself (e.g., for CGM).

If you want to see what a prior authorization request form looks like, check out this one for OptumRx.

My pharmacist told me I need a prior authorization. What happens next? 

  1. If your insurance company requires (and has not received prior authorization), your pharmacy will contact your healthcare professional.
  2. The healthcare professional will contact your insurance company and submit a formal authorization request.
  3. Your insurance plan may have you fill out and sign some forms.
  4. Your insurance plan will contact the pharmacy once it has approved or denied the request.

During this process, be sure to communicate with both your healthcare provider and your insurance company to see if they need any additional information. Prior authorizations usually take about a week to process – after that, check with your pharmacy to see if the request was approved. If the request was approved, you should be able to pick up your prescription from the pharmacy.

If it wasn’t approved, your pharmacy should be able to tell you why, and then you can decide to request an appeal.

As someone living with diabetes, you are your best advocate. Be prepared to track down the paperwork to make sure you receive the requested device or medication.

How can I check if I need a prior authorization?

Check your health plan’s policy and formulary (you can normally access these on the insurance company’s website) to see if any of your treatments require a prior authorization. Or, you can call the member services number found on the back of your insurance ID card to speak with someone directly.

How long do prior authorizations last?

Most approved prior authorizations last for a set period of time (usually one year). Once it expires, you’ll have to go through the prior authorization process again.

What happens if the prior authorization is denied?

  • You can request an appeal (which is often successful!)
  • You can pay the full cost for the medication or healthcare supply, without insurance coverage.

Want to learn more?

Check out this easy-to-read resource created by DiabetesSisters on prior authorizations, step therapy, and appeals.

What’s Worked for Other People with Diabetes? Hear from Them!

  • I was denied my first CGM in 2008 by a Blue plan and fought and won by knowing how to Google my payer’s medical policy and prove that I met coverage criteria. It helped that I was given the HCP line phone number by a nurse sympathetic to my cause, but I ended the call with an authorization code. – Melissa
  • My strategy has always been persistence pays (eventually the insurance company will give in, although they may have peculiarities to navigate. The doctor’s office is really key and many have specialists who only deal with insurance company issues [mine does]). I’ve been covered by 4 insurance companies over the past decade while at the same employer if that tells you anything about the evolving insurance market. My experience with Anthem was a hassle but predictable, United Healthcare was easiest to navigate, Aetna was straightforward but a pain and had some weird rules (Why does a precertification inexplicably expire at the end of a calendar year? My chronic illness did not expire at the end of the year.). – Scott
  • Do you have experiences with prior authorizations? Let us know!
diaTribe Series

Image source: diaTribe

This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

Can Continuous Glucose Monitors Help Change How We All Eat?

If you share with someone results from a study indicating that even “healthy” people often eat foods that cause harmful blood sugar spikes, they may believe you and understand the underlying reasons. However, they may be much more likely to act on this knowledge if they wear a device that shows them in real time […]
Source: diabetesdaily.com

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