In April 2017, Alan Zaslavsky was the inaugural speaker for the Will Manning Memorial Lecture at the University of Chicago’s Center for Health and the Social Sciences. Willard Manning was a leading researcher in health economics and an outstanding mentor who taught at the University of Chicago Harris School of Public Policy and in the Department of Public Health Sciences before his retirement in 2011. He died in 2014 after a long and distinguished career, which included his participation in the RAND experiment with Joseph Newhouse. Titled “Health Care Quality, Social Disparities, and Causality,” Zaslavsky discussed conceptual issues underlying research on health disparities.
Zaslavsky defined disparities in health care, based on work done by Tom McGuire in the IOM report Unequal Treatment, as group or groups receiving less or inferior care without a clinical basis. Thus, treating a group differently because of age may be acceptable, but expecting that a certain group will behave according to a certain stereotype (e.g., lower-income patients will not have good outcomes) and treating them as such is not.
Beyond implementing this normative conception of disparities, Zaslavsky’s work moves towards understanding predictive elements of disparities (what will happen based on what is seen) and causal elements—understanding why these behaviors lead to disparities and getting at the mechanisms underneath. Race or sex cannot be seen as inherently causal factors, meaning that one cannot attribute a disparity to that innate quality. Zaslavsky argues that the search for causes should be guided upward to the doctors and the systems within which they work. Stereotypes and ingrained ways of thinking impact the ways that certain groups are treated—and such systemic causes can be studied, identified and hopefully changed.
This approach is also reflected in the recent report Accounting for Social Risk Factors in Medicare Payment from the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine). The report focuses on disparities in post-hospital outcomes, and ways to measures them. Zaslavsky argues that a key question is whether disparities occur within or between hospitals. Is a disadvantaged group getting care at inferior hospitals because of referral patterns or insurance limitations, or do members of the group have inferior outcomes compared to other patients within the same hospital? These contrasting empirical “stories” have different implications for the design of quality-based incentive systems.