Monday, January 7, 2013

Technology, Innovation, Disparities, and the Elderly

Won't tech tools worsen health disparities in the U.S.?

This is a concern I've heard more than once from my colleagues in academia. (If you're not an academic and aren't sure what health disparities are, here's a handy summary from healthypeople.gov. Note that healthypeople.gov doesn't call out the elderly as prone to suffer disparities, but MedLine does.)

It's an understandable worry. After all, here are some common predictions I hear from the digital health community:
  • Smartphones, tablets, sensors, and apps will allow people to collect and monitor their own health data
  • Better access to information will allow people to make better health decisions, and will empower them to direct their own health care
Or take a look at this Digital Health Infographic, created by Paul Sonnier who runs LinkedIn's huge Digital Health Group:



Obviously, if you've spent any time providing clinical care to people who are poor, less educated, or elderly, it can be hard to imagine them donning a sweatband, digitizing themselves, and hustling up the self-empowerment stairs to a wonderful healthy future. (Where the heck are the people who have multi-morbidity or advanced chronic illness in this infographic, anyway?)

If better health will come through smartphones, tablets, and apps, then what happens to the health of those who can't afford to purchase them, or don't find them usable?

If better health comes to those who effectively use the internet and their own personal data to chart a better course for their own health, what happens to those who can't access this information, or can't sort through it effectively?

The median household income in 2011, according to the Census Bureau, was $50,054. IRS data from 2010 shows that to be in the top 50% of income in the U.S., you only need income of at least $34,338. To be in the top 25% corresponds to income of $69,126 or more. To be in the top 10% = $116,623 or more; to be in the top 5% = $161,579 or more. (And in case you are wondering how much income was required to be in the fabled 1% in 2010, it was at least $369,691.)

Also well known in academia: studies consistently show that both lower socioeconomic status and increased age correspond to greater disease burdens and worse health outcomes.

So in summary, we have technological innovations on the horizon, which is predicted to improve the health and wellbeing of those who can afford them and know how to use them -- a group already advantaged by affluence and generally good health.

Will these tech innovations worsen disparities?


Maybe. It would really depend on the circumstances. Specifically, disparities would be increased if:
  • The tech innovations actually meaningfully improve health outcomes.
  • The innovations don't become available to people of more modest means, lower health literacy levels, or different cultural backgrounds.

However, if tech innovations improve outcomes AND become available to a broader swath of the population, then disparities could potentially decrease a bit.

This doesn't seem far-fetched to me. There certainly is a digital divide in the country, both along age lines and along socioeconomic lines, but the price of technology is dropping and access is increasing. Health insurers may also be willing to subsidize use of new technologies, if health benefits are clear.

Should improving quality be a higher priority than reducing socioeconomic disparities?


My own answer to this question is definitely yes, especially when it comes to the elderly.

This is because even Medicare beneficiaries who are wealthy, white, and educated often suffer from crummy healthcare.

What do I mean by crummy? Here are some examples of problems I routinely discover in older people of higher socioeconomic status (you've probably come across them when it comes to healthcare for your parents or grandparents):
  • Prescription of medications that cause confusion and worsened balance
  • Dementia that goes undiagnosed for far too long; once diagnosed, inadequate education and support for family caregivers
  • Lack of care coordination among multiple specialists and care sites
  • Inadequate understanding of overall health status, health trajectory, and prognosis
  • Lack of non-pharmacological treatment for conditions such as depression, gait instability, pain, incontinence, and dementia behavior management
  • Procedures and diagnostic evaluations of unclear clinical benefit
  • Lack of clarification of values, goals, and care preferences
  • Inadequate symptom monitoring and management, including inadequate pain management
  • Frustration and confusion with the healthcare system


I could go on, but I'll stop there for now and go back to socioeconomic disparities and improving health quality.

We should definitely keep working on reducing health disparities due to socioeconomic status. The rich will always end up better off than the poor, but given the overall wealth of the US, people in this country should have pretty good health care at all levels of economic status.

However, the fact that even wealthy white educated Medicare beneficiaries suffer from poor health care is sobering. If the system can't do right by them, how can it hope to do right by the middle class, and lower middle-class? (The truly disenfranchised, such as those suffering from extreme poverty or severe substance abuse, will likely need special resources tailored to their needs.)

So as part of a multi-pronged strategy to improve the healthcare of older adults, it's valuable to look to the new tech tools and figure out which can help our more advantaged older patients with multiple chronic diseases. Once we've made headway on that challenge, we can work on disseminating effective tech tools to those with less income, or adapting them for people of lower educational levels or different cultural backgrounds.

Even if disparities remain, if every section of society has at least moved upwards in health quality, we'll be better off.

In a nutshell:


Many digital health innovations are most likely to be used by people who are younger, more affluent, and more educated. One can legitimately worry that these innovations will worsen health disparities in the U.S.

However, for innovations to significantly worsen disparities, they would have to both meaningfully improve health outcomes, and not be made available to people of lower economic status. Although the digital divide is real, access to digital tools is increasing for almost all levels of society. Payers may also eventually subsidize tools that have been shown to improve outcomes.

The Medicare population is one in which many suffer from inadequate health care, even when they are wealthy, white, and/or educated. Improving healthcare for older adults requires a multi-pronged strategy, and part of that strategy should be to identify which new digital health tools can improve care in those older adults who are able to access them.

Once suitable tools are developed and identified, additional efforts will be needed to disseminate and adapt them to a broader group of older adults, including those with lower incomes, lower health literacy, and of different cultural backgrounds.

(Disclosure: I have recently opted-out of Medicare -- see last FAQ for why -- and now only treat people who are more "advantaged." I admit that I need to believe that by piloting an alternative model of outpatient geriatric care and trying out new technologies with my patients, I'm still serving the cause of better healthcare for all older Americans.)

2 comments:

  1. Good luck Leslie. We have to evaluate technology "in the wild" to see what works for us and our patients. Most evaluations are carried out in pilot projects with artificial funding models. As a result when they are then released they generally fail. Sky we natively they gave the Venture Capital test, financiers with no knowledge or interest tree at in healthcare bankroll apps in the belief that those that make money are most beneficial to healthcare.
    The reality is that it is the tools used by dedicated healthcare providers to improve their patient's lives that make the difference. I look forward to following your journey, and I hope the people at Medicare take notice.

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  2. Thanks George! I doubt Medicare will ever notice what I'm doing, but perhaps we tech-oriented geriatricians can at least help each other spot the more useful tools. Hope you'll let me know when you come across anything that can help with on-the-ground outpatient practice.

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