“Low-value care” has been defined as care in which the potential for harm far outweighs possible benefits. When one has the opportunity to consider the phrase in conjunction with its definition, it evokes the notion that patients, their clinicians, and care team are discussing several dimensions of care, weighing the “pros” and “cons,” and arriving at a shared decision. In reality, low-value care is not experienced as a deliberative process. Clinicians often dismiss inquiries about services that may be low value using euphemisms such as “unnecessary,” “inappropriate,” or “wasteful,” without explaining why. This can leave patients wondering whether care is being withheld for more pernicious reasons including bias, rationing, rejection, and racism. This skepticism is particularly prevalent and acute in African American and Latinx communities, whose current and historical experiences have diminished their trust in the health care enterprise.
Without taking the time to deconstruct the many ideas that are trying to be conveyed by the term “low-value care,” the low-value care movement may be defeating the very cause it seeks to champion.
The Role Of Systemic Racism, Discrimination, Disparities In Outcomes
For African American and Latinx communities, the roots of racism and discrimination run long and deep, not just within the social and economic aspects of life but also in medicine and health care delivery. This history must be kept in mind when considering how to broach the subject of low-value care for these populations.
Medicine has mirrored the level of racial injustice and exploitation present in society today; the impact of racial disparities exists in everything from funding and representation in research to patient care and life expectancy. Contemporary studies indicate that systemic discrimination is associated with the elevated risk of a broad range of conditions, such as hypertension, breast cancer, and shorter life span. Indeed, health disparities are all too pervasive.
This confluence of systemic racism in health has beared out in persistent health disparities. Study after study, beginning in 1906 with W.E.B. DuBois, The Health and Physique of the Negro American, to the Healthy People series first published in 1979 to the Heckler Report on Black and Minority Health in 1985 to the Institute of Medicine’s report on Unequal Treatment in 2003, a prevailing message continues—African American and Latinx people have experienced and continue to experience consequential health disparities and low-value care relative to their White counterparts.
In light of the systemic racism within which our health care system developed, the abuses experienced by populations of color, pervasive evidence of unequal treatment, and the persistent underrepresentation of African American and Latinx people within the health professions, distrust runs deep, and it is understandable why African American and Latinx people might be suspicious of efforts to reduce purportedly low-value care.
In The Midst Of A Pandemic: Improving Trust Through Action
We need to look no farther than the current COVID-19 pandemic to bear witness to how the roots of systemic racism and low-value care have exacerbated and further damaged the health of communities of color. Relative to White populations, Latinx and African Americans are not only more likely to contract the virus but also disproportionally die, irrespective of geography, region, and age. And as vaccinations become accessible to the full society, Latinx and African Americans, almost predictably, have less access to vaccinations compared to their white White counter parts.
This once in a lifetime event, has unmasked the lack of effort made in truly confronting disparities and the impact it has on the health system and society. For an industry based on evidence, the data are here, present and every growing. This cannot continue.
African American and Latinx patients have been experiencing low-value care for centuries. Their approach to seeking health care—indeed to each and every health care encounter—is understandably accompanied by a healthy dose of skepticism. However, we can begin to provide better care for African American and Latinx patients—we do so by building equitable structures that provide high-value care to all.
We conclude that the term “low-value care” is a concerning term to use with a wide array of health care stakeholders, and it is an easily misconstrued and potentially volatile term to use with African American and Latinx communities. Thus, the most important thing for the health care system to do is ensure that patient populations receive care that is more beneficial than harmful. Let us set aside the term “low-value care” and begin anew with language that reinforces equitable access to care and treatment of African American and Latinx patients, their families, communities, clinicians, and care teams.
This moment calls for a re-examination of what low-value and high-value care means to the well-being of communities of color. Going forward, the systemic exploitation, inequitable treatment, and disparate health outcomes that have been experienced by African American and Latinx communities must be taken into account. We must find common concepts, language, and communication strategies to inform what is presently difficult for some to convey.
This work includes confronting the following questions: How do different communities define appropriate racially, culturally responsive care and better care? How does high-value care help address the realities of access to high-quality care for those who need it the most? How do we replace the racism baked into the foundation of medicine with an ethos of equitable care founded on the intentional building of trust among patients, communities, and the professionals and institutions that are charged with serving them? How do we ensure that health care as an industry is willing to act on what the voices of those experiencing inequities have been telling us, and centering them in collaborative efforts to increase equity?
To begin this work of building anew, we recommend the following to all health care stakeholders—patients, their physicians and clinicians, and health system leaders:
- Clearly affirm that all patients must derive high value from health care.
- Seek active engagement from African Americans and Latinx populations to develop appropriate concepts, terms, solutions, and communications strategies.
- Be willing to shift overall emphasis of the “low-value care movement” from care processes to structural strategies (for example, removing bias from clinical guidelines; including equity on quality dashboards) and ensuring care is equitable in terms of access, processes, and outcomes.
- Build on the annual National Healthcare Quality and Disparities Reports to measure and report levels of equity at several levels of the health system: nationally, by state, by community, and by health system.
- Develop policy and research to support findings and create space in the market to identify opportunities for changes in practice and behaviors.
- Include measurement of equity reporting on health outcomes as a standardized practice, to improve meaningful outcomes that produce high-value, high-quality care.
Although the health care system is founded on the resounding principle of “first do no harm,” it is at its core a system made of imperfect people functioning in an imperfect society. The concept of low-value care—care in which the potential harms outweigh its benefits—is a critically important one for all communities to understand, especially those that have experienced systemic harms. However, we cannot expect that the term, no matter how well-vetted within the health care industry, will carry the right set of meanings to African Americans and Latinx communities.
The terminology of “low-value care” needs to be reimagined with inclusion of African American, Latinx, and other racial and ethnic communities. This requires an equitable commitment and investment to forge a community-oriented approach to not only eliminate low-value care but increase high-value care among African American and Latinx populations. An alliance among stakeholders impacted by low-value care—patients and communities, public health, health care systems, professional and practitioner groups representing diverse communities, research funding organizations, and policy makers—is the best hope to achieving better care for African Americans and Latinx populations and to collectively address key issues that perpetuate health inequities.
The authors acknowledge AcademyHealth, The Donaghue Foundation, ABIM Foundation, and the Thematic Working Group on Low-Value Care among African American and Latinx Populations including Dawn H. Johnson, MSN, RN; Jung G. KimDavid Meltzer MD, PhD; Mary Ann Perez-Brescia, MSN, RN; Eva M. Powell, MSW; Erica Shelton, MD, MPH, MHSJanice Tufte. This commentary and the Thematic Working Group on Low-Value Care among African American and Latinx Populations is jointly sponsored by AcademyHealth, The Donaghue Foundation, and the ABIM Foundation. Reyes was supported by NIH/NIA UCLA Resource Center for Minority Aging Research/Center for Health Improvement of Minority Elders (P30AG021684-16), and from NIH/NCATS UCLA Clinical & Translational Science Institute (UL1TR001881).