Knowledge is power when it comes to managing your own health, but many consumers may be unaware of some hidden hazards that could compromise their care. From behind the scenes policy changes to insidious financial arrangements between providers and private industry, today’s fast-changing health care environment requires constant monitoring. Fortunately, patients can take simple steps to ensure that they—and their families—receive the best health care available.
Gender Bias
In this day and age, it’s hard to believe that gender plays a role in determining something as critical as medical treatment choice. But according to a growing body of research, women are less likely than men to receive important procedures that can profoundly affect their long-term health and survival. Studies of hospital discharge records show that women are 25 percent to 30 percent less likely to receive kidney transplants than men and half as likely to receive coronary bypass surgery.
In the prevention, diagnosis and treatment of stroke, gender disparities are particularly striking. In 2004, University of Michigan researchers analyzed the records of 381 stroke patients and found that women were less likely to get critical tests that can reduce their risk of a second stroke. A similar study by researchers at Massachusetts General Hospital from 2006 found comparable disparities in early prevention measures and drug therapy prescribing patterns. These differences in testing and treatment explain, in part, why women fare worse over the long term and die more often after a stroke than men.
But gender bias cuts both ways. Because depression is often viewed as a “women’s disease,” men are less likely to be diagnosed with the disorder. Men are also more likely to receive higher risk treatments for heart disease, which can lead to complications.
Why this is the case is unknown. According to Lynda Lisabeth, a University of Michigan epidemiologist and author of the stroke study, it’s not clear if male and female patients seek out different treatments or if physicians have biases that influence care.
A report by the American Medical Association, however, offered a different interpretation. It concluded that stereotypes and societal prejudices that value men’s work over women’s could be at the heart of the matter. “Perhaps a general perception that men’s social obligations or the value of their contribution to society is greater than women’s fuels these disparities. Altering one’s work schedule in order to accommodate health concerns may be viewed as more difficult for men than women,” states the report.
Whatever the cause, the bottom line is: Patients—male or female—need to be their own health-care advocates. Everyone should seek advice from multiple experts before undergoing any high-risk procedure, says Jessie Gruman, president of the nonprofit Center for the Advancement of Health in Washington, D.C.
“Patients can guard against gender bias by going through another doctor and getting a second opinion’” she advises.
Limited Access
When emergencies arise, it’s comforting to know that you can get the care that you need, when you need it. But in some pockets of the country, emergency room doctors and surgical specialists are simply unavailable.
In states without laws to control malpractice insurance rate increases—Florida, Pennsylvania and Nevada, to name a few—some doctors who perform high-risk procedures have closed up shop or restricted services in order to avoid the escalating fees.
The phenomenon, while not widespread, can dramatically impact small towns, rural counties and urban areas with a limited physician supply. For example, pregnant women in one Mississippi county must travel 65 miles to get obstetrics care because the local hospital closed its delivery unit, according to a 2003 report by the General Accountability Office (GAO). The hospital’s family practitioners stopped providing delivery services in order to avoid a more than 65 percent increase in their annual malpractice premium rates.
Pennsylvania doctors face a similarly difficult malpractice environment. According to a 2005 survey by Harvard researchers, 88 percent of Pennsylvania specialists who do high-risk procedures—obstetricians and neurosurgeons, for example—had been sued at some point during their career, and 48 percent had been sued in the previous three years. As a result, one-half planned to restrict their practice because of liability concerns.
The threat of malpractice lawsuits may also impact the number of physicians who choose to go into the field of radiology. According to Dr. Etta Pisano, chief of breast imaging at the University of North Carolina, Chapel Hill, the most frequent cause for a malpractice claim is a delay in breast cancer diagnosis—a key reason why breast imaging is considered a high-risk procedure in the eyes of insurers.
This tense legal environment—coupled with lower reimbursement rates for mammograms—contributed to the 5 percent decline in the number of physicians qualified to interpret breast-imaging exams between 2001 and 2004, according to the GAO. A 6 percent drop in breast-imaging facilities has further restricted access to mammograms in some areas.
Again, rural counties with underlying access problems appear to be the hardest hit by the decline. A second GAO report published in 2006 found that after the only mammography unit in one Virginia county closed, women must now travel 60 miles to obtain screening services–an obstacle that’s particularly onerous for low-income women.
“Right now it looks like we’re OK in terms of capacity, but it sounds like we’re on the verge of having some problems in some counties in the future,” says Dr. Pisano.
Given these looming access issues, women in shortage areas should schedule mammography screenings well in advance and those over age 40 should plan for a visit once a year to ensure that they receive optimal preventive care.
Follow the Money
An ideal physician champions his patients—but these days corporate marketing and economic pressures make the doctor-patient relationship more complicated. An intricate web of financial arrangements and inducements permeate the health-care system—and physicians are not immune to such incentives.
The subtle courtship that occurs between health-care product suppliers and physicians takes many forms. Pharmaceutical and device companies offer gifts, cash incentives, speakers fees, medical education trips and consulting agreements to doctors with one goal in mind: to influence prescribing and treatment behavior. Companies may also pay physicians a “finder’s fee” for referring patients to their clinical trials. Such incentives can cloud doctors’ judgment and seduce some into choosing treatments or products based on their relationships with private companies rather than evidence or unbiased medical opinion.
An important 2000 article in JAMA, the journal of the American Medical Association, found that the $8.5 billion that pharmaceutical companies spend on physician marketing has a strong effect on prescribing practices, even though most doctors deny that industry gifts and visits influence their behavior.
The analysis by psychiatrist Ashley Wazana of McGill University, in Montreal, Canada, showed that doctors’ contact with pharmaceutical representatives begins in medical school and continues at a rate of four times per month after degree completion. After interacting with and receiving some gift or service from pharmaceutical representatives, doctors increased their prescriptions of marketed drugs and were more likely to choose such drugs over existing alternatives even when the marketed drug offered little or no advantage.
“Physicians respond to financial incentives just like anyone else does,” argues Georgetown public policy professor Jean Mitchell who studies utilization and conflict of interest issues around physician-owned hospitals. “Medicine is a business and doctors are businessman.”
Mitchell’s research has shown that costs, use of services and profits all increase at physical therapy centers where referring physicians have a financial stake in the clinics’ success. Her work also indicates that doctors who jointly own heart hospitals tend to refer patients with better, higher paying insurance to their own facilities.
Mitchell’s findings are highly controversial and have invited speculation that physicians are cherry picking the most lucrative patients for their own hospitals and referring patients for unnecessary services to boost profits.
However, many physicians who invest in specialty hospitals argue that such facilities offer higher quality, more focused care that is tailored to specific conditions or diseases.
Regardless, knowing where your doctor’s income comes from would be useful information to have in your back pocket if you’re facing a critical health-care decision. However, accessing this information can be a challenging—and uncomfortable—task.
“It’s easier said than done,” says Gruman of the nonprofit Center for the Advancement of Health. “Just by asking the question, you’re suggesting that they’re unethical and that’s a difficult thing for patients to do,” she says. “Particularly with regard to treatment choices and diagnosis, the best strategy is always to get more data points—to get a second opinion,” she advises.