Month: January 2016

Diversity in the Health Professions: a ‘Leaky Pipeline’

This post was originally published for the Health Policy$ense blog of the Leonard Davis Institute of Health Economics.

Despite decades of calls for increased representation of minorities in the health professions workforce, we are very far away from a workforce that reflects this nation’s diversity. Underrepresented minorities make up 31% of the general population, but just 15% of medical school students and 13% of dental students. A new study helps us understand the barriers minority college students face in pursuing medical and dental careers.

In Academic Medicine, Brandi Freeman and colleagues, including LDI Senior Fellows Judy Shea and David Grande, report on focus groups they conducted with undergraduates from minority backgrounds that are underrepresented in medicine, including Blacks, Latinos, and Native Americans. The one-hour focus groups, involving 82 diverse students across 11 colleges, highlighted several challenges: inadequate institutional resources for academic success and clinical opportunities; strained personal resources such as lack of financial resources or familial pressure; inadequate guidance and mentoring to assist with key career decisions; and societal barriers such as work-life balance concerns or job uncertainty.

The quotes from the focus groups illustrate the challenges, insecurities and uncertainties that these students face:

…somebody else who never worked—had to work for anything and their parents paid for all their college, it’s their GPA is obviously going to be higher because all they had to focus on was school.

It’s kind of a disadvantage almost if you don’t have family that—or someone that will let you come into their workplace and follow them around. […] For people who don’t have that as an option, it makes us look bad.

I feel kind of lost. I know I want to be there, but I just don’t know how to get there.

What happens if you never get matched, I guess? Because that’s a possibility and you don’t go through residency, so you’re stuck with an MD who can’t practice medicine.

The focus groups were conducted as part of the Tour for Diversity in Medicine, an effort from underrepresented minority physicians and dentists to encourage students of diverse backgrounds to pursue careers in the health professions. The focus group approach to understanding root causes of the “leaky pipeline” is important, the authors say, since past studies have relied on quantitative data such as academic achievement, focused on a single institution, or captured perspectives from minority students who have already become health professionals. This new study is more qualitative, involves multiple institutions across the nation, and captures the undergraduate perspective.

The authors suggest that external programs, such as the Summer Medical Education Program(SMDEP), can strengthen support for students at resource-limited institutions. To address strained personal resources and familial barriers, the authors recommend educating families at the high school level to familiarize them with the medical training process at an earlier stage. At a higher level, the authors suggest that policy changes, such as regulation of medical resident work hours, can change perceptions of work-life balance.

Increasing the diversity of the workforce is important because health professionals from underrepresented backgrounds disproportionately serve minority and other medically underserved populations. In addition, minority patients tend to receive better care from practitioners of their own race or ethnicity, particularly in primary care and mental health settings. As part of a series on how the Affordable Care Act affected minority health last January, we wrote about workforce diversity. The ACA invested $100 million to expand scholarships and loan repayments for disadvantaged and minority students; provided large grants to historically Black Colleges and Universities for academic support, faculty development, and research surrounding health issues; and created $67 million in Health Profession Opportunity Grants (HPOG) for low-income families.

The authors of the focus group study point out that the perceived and actual barriers for minority students in the health professions pipeline are similar to those for other science degrees and fields, and that interventions can affect diversity across a broader set of careers. One closely related field is health services research, which the Leonard Davis Institute and other Penn institutions support through the Summer Undergraduate Minority Research (SUMR) program. Now in its 16th year, SUMR provides stipends for students to conduct research with Penn faculty on a topic of their choice. These programs are an important step in addressing barriers for minorities who want to help advance the nation’s health.

Will price transparency affect hospital provision of less profitable services?

This post was originally published for the Health Policy$ense blog of the Leonard Davis Institute of Health Economics.

The question of whether and how much hospitals cross-subsidize unprofitable services with more profitable ones is an important one, especially as wide variation in hospital pricing within and across markets is documented. If prices become more transparent, and a hospital’s revenues from high-margin services drops, will hospitals reduce the amount of less profitable services they provide?

For a hospital’s bottom line, not all service lines are alike. Some are quite profitable (such as cardiology or neurosurgery) while others are low- or no-margin (such as psychiatry, substance abuse treatment, and trauma), partly because they attract uninsured and underinsured patients and partly because operating margins for these services are slim and in some cases even negative. Cross-subsidies are often considered the principal mechanism through which hospitals provide unprofitable care, thereby fulfilling their social missions. But they’re hard to detect in hospital accounting systems.

In the first study to quantify this effect, LDI Senior Fellows Guy David and Lawton R. Burns and colleagues Richard C. Lindrooth and Lorens A. Helmchen, estimated the magnitude of cross-subsidies within hospital systems. They studied how market entry by specialty cardiac hospitals (high-margin services) affects the provision of psychiatric, trauma, and substance abuse care (low-margin services) by general hospitals. They found that general hospitals facing new specialty competition decreased their admissions for unprofitable services and increased their admissions for a profitable service (neurosurgery).

Consistent with cross-subsidization, reductions in the volume of psychiatric, substance abuse, and to a lesser extent trauma care were greatest among the hospital systems most exposed to a potential loss in volume of their cardiac services. Their model estimated reductions of 15% for inpatient psychiatric admissions, 18% for substance abuse admissions, and 5% for trauma admissions.

Their findings indicate that intensified price competition for profitable service lines due to price transparency may have the unintended consequence of reducing the volume of less profitable, though important, services a hospital provides. But perhaps that would not be a bad thing. As pointed out in the study, research from industries such as telecommunications and transportation finds that regulated cross-subsidies are a highly inefficient way to supply unprofitable services (especially considering the alternative of direct subsidies coupled with competition).

As David and colleagues note, their results should make us question whether to continue to rely on hospitals’ assumed ability to cross-subsidize unprofitable, yet social desirable services.  It may be that internal cross-subsidization is not an efficient way of reaching social goals, and that setting Medicare and Medicaid reimbursement at a level high enough to preserve access to such services is a better option. The movement toward price transparency may hasten that day of reckoning.