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So. I was prodded to problematize blanket narratives of ‘overtreatment’- at least in the US- given the legacy of segregated hospitals, patient dumping, severe underfunding of Indian health services + the fact that a minority of doctors treat Black, Latinx, indigenous patients
I talk quite a bit #onhere about rationing of healthcare- by employment status, insured status, age, family status, diagnostic status
I also talk about how the spatial arrangement of care in social & geographic space reflects a marketized system that was not oriented around population health
zooming out, we find w/n US medicine a broader pattern of:
- a majority white profession trained to treat white PTs
- among them, a minority treat ‘minority’ PTs- esp in rural, medically underserved areas, & the Rez
- those who do are often generalists who are paid less
So, while patients with the best access to care are likely to be ‘overtreated’, those with poorer access (Black, Latinx, indigenous, immigrants, residents in rural areas, disabled people) are less likely to even get a dx (more like to get a delayed dx, or mis-dx) or treatment
The problem with conversations about ‘overtreatment’ is that they focus at the scale of the clinic, without attention to the ways that the health care system is riddled with modes of rationing, which prevents some from successfully seeking care. #HealthCareEquity
In other words, conversations about ‘overtreatment’ focus on those patients who were able to clear the hurdles. If you’re also including people with delayed dx or misdiagnoses, then you should specify, because ‘overtreatment’ may be the only corrective that clinicians have then.
Also: consider the ways that health system payment arrangements can be a disincentive for physicians & other health care providers to locate in certain places- driving shortages. E.g. Puerto Rico, where Medicaid is a block grant program- underfunded, inflexible, cruel
This conversation should be multi-scalar, really. On one hand, a serious examination of this health system- it’s spatial & social arrangements & the priorities they reflect. The lives they devalue via rationing.
OTOH, revisiting the ways that doctors are taught to treat white PTs as the default. Race-based medicine is based on heuristics that collapse social categories of difference with biology.

Examples: pain scales, spirometer readings, creatinine numbers
And I wanted to add this reference:

Skinner J , Chandra A , Staiger D , Lee J , McClellan M. (2005). Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients. Circulation. 112(17): 2634 –41

Free access here: ahajournals.org/doi/full/10.11…
In 2005, an estimated 30% of physicians in the US treated nearly 100% of ‘minority’ patients. And those patients generally had a heavier burden of disease, poorer health.

Under the current system, they are more expensive, less profitable (more uncompensated care).
... which makes me wonder: “evidence-based medicine for whom?”

Between race-based medicine & the rationing of care, it’s clear that conversations about ‘overtreatment’ cannot be isolated from the a deeply inequitable health system.
Last note: while patient dumping is technically illegal, private hospital systems now divert ambulances to public hospitals to avoid providing care to high-need, un(der)insured patients & reduce the quantity of uncompensated care #HealthCareEquity
Anyway, this 2017 article is fitting healthaffairs.org/doi/abs/10.137…

This cited article is also relevant: Bach PB , Pham HH, Schrag D, Tate RC , Hargraves JL. (2004) Primary care physicians who treat blacks and whites. N Engl J Med. 351(6): 575 – 84
"Between 2004 & 2012, per capita expenditures for the poorest quintile fell at a rate of $19.27 annually—3.7% over the eight-year period. Meanwhile,
health expenditures for the wealthiest group outpaced those of the three middle quintiles" (19.7% vs 12.5%)
Basically, b/w 2004-12, health spending fell among lowest-income people in the US (a decrease that began under Reagan, post-cuts to Medicaid and Medicare), with the fastest growth among high-income USians with private plans. #HealthCareCostCutting #HealthCareEquity
Recall the health-wealth gradient (wherein lower-SES people tend to have poorer self-reported health status, higher burden of illness compared w/ their higher-SES counterparts)

...falling health spending among the poorest patients reflects the priorities of a marketized system
Excellent examples of undertreatment of Black and/or low-SES patients from @KRayHSR 👇🏾
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