Thread by @awgaffney

Some thoughts on this new blog post in @Health_Affairs by Caroline Kelly, @WF_Parker, and @haroldpollack, which raises some very important issues, but which I have some points of disagreement with.

healthaffairs.org/do/10.1377/hbl…

They rightly highlight disparities in resources between hospitals taking care of poor and rich patients — or predominantly white vs. Black patient populations — during the COVID-19 pandemic. They emphasize how such disparities could exacerbate class/racial disparities in outcomes

It's an important issue.  I wrote about such "supply inequity" in COVID-19 last year: resource maldistribution is one more manifestation of Hart's "Inverse Care Law", or idea that availability of healthcare is inversely correlated with the need for it.

thebaffler.com/salvos/bill-of…

A particularly clear manifestation of the mismatch of supply and need in ICU care is this 2020 study in @Health_Affairs, which found that almost no high income communities had zero ICU beds, but about half of low income communities did. healthaffairs.org/doi/abs/10.137…

So what are my issues with the blog post? First, I think we have to be very cautious in making assertions about differentials in COVID-19 ICU mortality between hospitals, for reasons I wrote about this in this earlier thread.

https://twitter.com/awgaffney/status/1366053719666753539?s=20

(In brief, it's not just differences in patient characteristics per se: hospital / ICU supply strain can lead to different decisions about admission / ICU triage, that — even assuming no actual impact on outcomes — may appear to worsen outcomes in observational studies.)

Controlling for all of these factors can be difficult (as in studies examining outcomes among Medicaid insured vs. privately insured). Invariably, the health programs and providers of low-income patients "look worse."

It is a fine line, however, because the supply inequalities are real — and greater equity is critical. So my bigger issue is with solutions. They emphasize regionalization — i.e. facilitating transfers to (presumably tertiary) "respiratory centers of excellence" ...

I agree that more regional integration / health planning is needed, as I wrote about earlier: dissentmagazine.org/article/bring-…

And their points about doing more to ensure that patients who need a tertiary center can be transferred there is right.

But there's a couple of issues

First, during the COVID-19 pandemic at least, basically all ICU capacity was needed during the big surges — including in community hospitals. So this is much different from something like, say, lung transplant, where you can (and should) tightly limit the centers that provide it

Second, even outside the pandemic, respiratory failure is pretty common. And transferring patients far from community / homes / families places real strains that need to be considered.

But more importantly, I worry that greater regionalization within the context of the current US health financing system could potentially exacerbate disparities between hospitals — that is to say, funnel yet more resources to the already-most-resources hospitals.

Now to be fair, the authors emphasize increased Medicaid reimbursements to improve care at all hospitals. But absent deeper reform I think greater disparities among systems could be a reality.

Overall, the points they raise are important, and we certainly need more discussion on the issues of racial/ethnic, economic, and geographic inequalities in healthcare supply infrastructure (I'd be curious to hear @Arrianna_Planey's thoughts on this!).