實現性和性別少數群體的三重目標
資料來源：Michael Liu, M.Phil., Sahil Sandhu, M.Sc. & Alex S. Keuroghlian, M.D., M.P.H. / n engl j med 387;4 nejm.org July 28, 2022 / 財團法人台灣紅絲帶基金會編譯
最近頒布和提議的立法威脅到美國性和性別少數群體 (sexual and gender minority, SGM) 成員的基本權利。其中許多政策損害健康並限制獲得醫療保健的機會。例如，德克薩斯州州長格雷格·阿博特（Greg Abbott）發布了一項指令，調查父母在為孩子尋求性別確認照護時是否虐待兒童，佛羅里達州根據立法禁止在課堂上討論性取向和性別認同（sexual orientation and gender identity , SOGI），反對者稱之為「不要說同性戀」法案。儘管受到主要的國家醫療組織的反對，並且有大量證據顯示這種照護顯著降低了跨性別青少年的自殺傾向和不良的心理健康結果，但其他將提供性別確認照護予以定罪的法案已經被提出。
隨著政策制定者繼續針對著性和性別少數者為目標，醫療保健部門可以在減輕由此造成的傷害和倡導以證據為基礎的政策保護在健康和福址方面上發揮關鍵作用。我們相信，三重目標框架——包括增強患者的照護體驗、改善人口健康和降低人均照護成本——可以幫助確定現有挑戰和下一步促進性和性別少數者的健康。
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性和性別少數者經常有負面的醫療保健經歷。例如，跨性別患者在醫療保健中經常成為歧視的目標； 2015 年的一項全國調查發現，23% 的跨性別成年人避免了必要的醫療保健，因為他們害怕被醫療提供者虐待。在同時也是邊緣化種族或族裔群體成員的跨性別成年人中，這一比例尤其高，這顯示了跨性別恐懼症和種族主義的交叉性負擔。在女同性戀中，對歧視的恐懼導致子宮頸癌抹片檢查的比率低於異性戀女性，儘管她們有額外的子宮頸癌風險因素。
與普通人群相比，性和性別少數者的心血管疾病、肥胖症、癌症和性傳播感染（包括 HIV、人類乳突病毒、梅毒和C型肝炎）的發病率更高。心理健康問題，包括抑鬱、焦慮和物質使用障礙，並且更有可能嘗試自殺。身心健康狀況不佳與少數群體壓力（與屬於邊緣化群體有關的壓力）、歧視性政策和照護上障礙等因素有關。
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沒有足夠的信息來比較性和性別少數者和非性和性別少數者之間的醫療保健支出，主要是因為性取向和性別認同 (SOGI) 數據沒有定期地收集或包含在商業和公共索賠之數據集中。衛生與公眾服務部 (HHS) 2021 年的一份報告發現，與非性和性別少數者人相比，性和性別少數者更有可能因為費用和擔心支付醫療費用而延遲醫療照護。此外，儘管性和性別少數者的心理健康狀況較差且創傷負擔較高，但仍有 18% 的性和性別少數者（相較於非性和性別少數者為4%）因費用原因延遲了諮詢或治療。而主要由性和性別少數者使用的某些醫療保健服務也可能過於昂貴或保險不足。根據運動促進計畫，截至 2022 年 4 月，只有 24 個州和華盛頓特區的醫療補助計畫 (Medicaid programs) 明確涵蓋了對跨性別者的性別肯定照護。在擴大性和性別少數者的保險範圍方面取得了一些進展，主要是根據「平價醫療法案」，並通過增加雇主贊助的配偶與婚姻平等相關的保險機會。展望未來，有幾個步驟可以支持數據收集、融資模式、勞動力發展和社會保護，以改善性和性別少數者的健康。這些步驟為醫療保健部門提供了一個機會，可以與拜登總統最近於 2022 年 6 月 15 日簽署的行政命令保持一致，並在此基礎上再接再厲，以促進性和性別少數者的平等。
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首先，醫療保健部門可以收集額外的標準化的性取向和性別認同 (SOGI) 數據，為質量改進、研究和政策舉措提供量身定制的信息。當前大多數性和性別少數健康數據是從國家調查中收集的，而不是從電子健康記錄 (EHR) 或索賠數據庫中收集的。從 2016 年開始，衛生資源和服務管理局 (the Health Resources and Services Administration ,HRSA) 要求具有聯邦資格的衛生中心報告其使用獲准的問題去收集患者的性取向和性別認同數據。衛生中心提供免費定制的培訓以支持採用； 2016 年至 2019 年間，此類設施為至少讓 75% 的患者在收集性取向和性別認同 (SOGI) 數據的百分比從 14.9% 增加到 53.0%。
Medicare 和 Medicaid（註1）服務中心可以考慮將類似要求和培訓作為聯邦支付和質量報告計畫的一部分（例如，針對提供者基於績效的激勵支付系統和 Medicare Advantage 計畫的 Medicare C 部分報告要求）。自 2018 年以來，衛生與公眾服務部要求所有透過有意義使用激勵計畫認證的電子健康記錄 (EHR) 系統都能夠收集性取向和性別認同數據，但它不要求醫療保健組織系統地收集這些數據。來自 Medicaid 的州機構、州健康交易所和商業保險公司的額外的性取向和性別認同數據收集之激勵措施和要求，也可以促進付款人之間的一致性。未來的努力可以支持在電子健康記錄中採用標準化的性取向和性別認同數據元素，以符合更新的 2021 衛生與公眾服務部之相互可操作性標準。
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第二、收集更多完整數據可以推動支付改革以推進三重目標。衛生系統和支付者可以根據性取向和性別認同數據針對與健康結果、利用率和患者體驗相關的措施進行分層，以生成質量改進報告。然後，支付者可以將支付與新興的基於價值的支付模式下的公平措施聯繫起來，例如透過獎勵報告和減少性和性別少數健康差異的獎金。綜合數據還可以為政府安全網和公共衛生計畫提供信息。衛生資源和服務管理局資助了歷來專注於性和性別少數社區的聯邦合格醫療中心，例如波士頓的 Fenway Health（作者當中的一位工作的地方），並支持 Ryan White HIV/AIDS 計畫以提高愛滋感染者照護的可及性和質量，而這疾病正不成比率地影響性和性別少數者。 衛生與公眾服務部可以使用全面的患者數據來優先填補照護空白，並解決生活在服務不足和資源匱乏社區的性和性別少數者未滿足的需求。
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第三，需要發展勞動力，以確保衛生專業人員能夠支持性和性別少數者的特定需求。 2009-2010 年對美國和加拿大醫學院的調查發現，學生接受性和性別少數相關的醫學教育的中位數為 5 小時，33% 的學校沒有提供性和性別少數相關的臨床培訓。醫學教育聯絡委員會或研究生醫學教育認證委員會並未明確的要求將性和性別少數特定的醫療保健主題納入課程。最近對 120 個美國內科醫學計畫的住院醫師所進行的一項研究顯示，在評估性和性別少數健康之基礎知識的基準評估中，其平均得分為 50% 至 52%。
醫學院和住院醫師計畫可以建立能力並引入由性和性別少數健康專家所開發、審查和提供的性和性別少數健康課程。教師可以利用由專注於性和性別少數健康的組織策畫的年齡培訓資源，例如芬威學院的國家 LGBTQIA+ 健康教育中心。綜合內容和實踐經驗可以貫穿核心課程，以擴大以往僅限於選修課和課外活動的培訓。
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最後，醫生及其專業組織可以反對有害的立法和保護性政策，以解決性和性別少數健康的上游政治和社會決定因素。儘管最近取得了進展，但基於性取向和性別認同的明確和廣泛的保護並不是聯邦法律的共同特徵；相反的，在很大程度上保護取決於異構性的州和市政府層級的政策。 22 個州仍然允許對性和性別少數青少年進行轉換治療，儘管轉換治療和欺凌與心理困擾和自殺有關，卻只有 23 個州和華盛頓特區禁止在學校進行反對性和性別少數之欺凌。
確認基本權利的政策已被證明可以緩解性和性別少數者中少數群體之壓力。例如，準實驗分析發現，婚姻平等的實施顯著降低了性和性別少數青少年的自殺率和性和性別少數成年人的心理健康求診。聯邦立法需要為這些人群提供廣泛而明確的保護；其中一項法案是《平等法案》，該法案將修訂 1964 年民權法案，明確禁止基於性取向和性別認同上的歧視。研究人員可以繼續調查反性和性別少數立法的健康後果以及保護性政策和介入措施的潛在好處。
由於政策制定者危及性和性別少數社區的健康和醫療服務的獲取，我們認為醫療保健部門應重新致力於支持這些人群的健康公平。三重目標為提供者、支付者、研究人員和政策制定者提供了一套共同的目標，以保護性和性別少數者的健康。醫療保健部門可以致力於為所有性取向和性別認同的人提供公平的資源分配、照護體驗和健康結果。
本文作者提供的披露表可在 NEJM.org 上獲取。(M.L., S.S., A.S.K.)來自哈佛醫學院；(A.S.K.) 亦服務於芬威研究所芬威健康和麻薩諸塞州總醫院精神病學系——都在波士頓。Liu先生和 Sandhu 先生對本文做出了同等貢獻。本文於 2022 年 7 月 23 日在 NEJM.org 上發表。
註1. Medicare 和 Medicaid ：
Medicare是美國一項國家的醫療保險計畫，創立於1966年，隸屬於美國社會安全保險署（SSA），現由聯邦醫療保險和聯邦醫療補助服務中心（Centers for Medicare & Medicaid Services, CMS）負責管理。主要為65歲及以上的美國人提供醫療保險，也為經由美國社會安全保險署認定的某些年輕殘障人士，以及患有腎功能衰竭，還有肌萎縮性脊髓側索硬化症（ALS，或稱漸凍人症）的人士提供醫療保險覆蓋。
Medicaid 是美國一項聯邦和州的計畫，旨在幫助一些收入和資源有限的人支付醫療保健費用。 Medicaid 還提供 Medicare 通常不涵蓋的福利，包括療養院照護和個人照護服務。這兩個計畫之間的主要區別在於，Medicaid 為低收入人群提供醫療保健費用，而 Medicare 為老年人提供健康保險。對於同時擁有 Medicaid 和 Medicare 的人，還有雙重健康計畫。美國健康保險協會將 Medicaid 描述為「針對收入和資源不足以支付醫療保健的所有年齡層的人之政府保險計畫。
Achieving the Triple Aim for Sexual and Gender Minorities
Michael Liu, M.Phil., Sahil Sandhu, M.Sc., and Alex S. Keuroghlian, M.D., M.P.H. / n engl j med 387;4 nejm.org July 28, 2022
Recently enacted and proposed legislation threatens the fundamental rights of members of sexual and gender minority (SGM) groups in the United States. Many of these policies harm health and limit access to health care. For example, Texas Governor Greg Abbott issued a directive to investigate parents for child abuse when they seek gender-affirming care for their children, and Florida prohibited discussions about sexual orientation and gender identity (SOGI) in classrooms under legislation that opponents call the “Don’t Say Gay” bill. Other bills that would criminalize the delivery of gender-affirming care have been introduced, despite opposition from major national medical organizations and substantial evidence that such care significantly reduces suicidality and poor mental health outcomes among transgender adolescents.
As policymakers continue to target SGM people, the health care sector can play a critical role in mitigating resulting harm and advocating for evidence-based policies protecting health and well-being. We believe the Triple Aim framework — which consists of enhancing patients’ care experiences, improving population health, and reducing percapita costs of care — can help identify existing challenges and next steps for promoting SGM health.
SGM people often have negative health care experiences. For example, transgender patients are frequently targets of discrimination during health care encounters; a 2015 national survey found that 23% of transgender adults avoided necessary health care because of fear of mistreatment by providers. Rates were especially high among transgender adults who were also members of marginalized racial or ethnic groups, which demonstrates the intersectional burdens of transphobia and racism. Among lesbian women, fear of discrimination drives lower rates of Pap testing than those among heterosexual women, despite their additional risk factors for cervical cancer.
As compared with the general population, SGM people have higher rates of cardiovascular disease, obesity, cancer, and sexually transmitted infections, including HIV, human papillomavirus, syphilis, and hepatitis C. They also have substantially higher rates of certain mental health problems, including depression, anxiety, and substance use disorders, and are more likely to attempt suicide. Poor physical and mental health is linked to factors such as minority stress (stress associated with belonging to a marginalized group), discriminatory policies, and barriers to care.
There is not enough information to compare health care expenditures between SGM and non-SGM people, primarily because SOGI data are not routinely collected or included in commercial and public claims data sets. A 2021 Department of Health and Human Services (HHS) report found that SGM people are more likely than non-SGM people to delay care because of cost and to worry about paying medical bills. In addition, 18% of SGM people (vs. 4% of non-SGM people) delayed counseling or therapy because of cost, despite SGM populations having worse mental health and a higher trauma burden. Certain health care services used primarily by SGM people may also be prohibitively expensive or inadequately covered by insurance. According to the Movement Advancement Project, as of April 2022, Medicaid programs in only 24 states and Washington, D.C., explicitly covered gender-affirming care for transgender people. Some progress has been made on expanding insurance coverage among SGM people, primarily under the Affordable Care Act and through enhanced opportunities for spousal employer-sponsored insurance related to marriage equality. Moving forward, several steps could support data collection, financing models, workforce development, and social protections to improve health among SGM people. These steps offer an opportunity for the health care sector to align with and build upon the executive order that President Biden recently signed, on June 15, 2022, to advance equality for SGM people.
First, the health care sector could collect additional standardized SOGI data to inform tailored quality-improvement, research, and policy initiatives. Most current SGM health data were collected from national surveys, rather than electronic health records (EHRs) or claims databases. Starting in 2016, the Health Resources and Services Administration (HRSA) required federally qualified health centers to report patient SOGI data that are collected using approved questions. Health centers were provided free, customized training to support adoption. Between 2016 and 2019, the percentage of such facilities collecting SOGI data for at least 75% of patients increased from 14.9 to 53.0%.
The Centers for Medicare and Medicaid Services could consider similar requirements and training as part of federal payment and quality-reporting programs (e.g., the Merit-Based Incentive Payment System for providers and Medicare Part C reporting requirements for Medicare Advantage plans). Since 2018, HHS has required all EHR systems certified under the meaningfuluse incentive program to be capable of collecting SOGI data, but it does not require health care organizations to systematically collect these data. Additional SOGI data-collection incentives and requirements from Medicaid state agencies, state health exchanges, and commercial insurers could advance alignment among payers. Future efforts could support the adoption of standardized SOGI data elements in EHRs, in line with updated 2021 HHS interoperability standards.
Second, collection of more complete data could drive payment reform to advance the Triple Aim. Health systems and payers could stratify measures related to health outcomes, utilization, and patient experience according to SOGI to generate quality-improvement reports. Payers could then link payment to equity measures under emerging value-based payment models, for instance by awarding bonuses for reporting on and reducing SGM health disparities. Comprehensive data could also inform government safety-net and public health programs. HRSA has funded federally qualified health centers that have historically been focused on SGM communities, such as Fenway Health in Boston (where one of us works), and has supported the Ryan White HIV/AIDS Program to improve access to and quality of care for people with HIV, which disproportionately affects SGM people. HHS could use comprehensive patient data to prioritize filling care gaps and addressing unmet needs among SGM people living in underserved and underresourced communities.
Third, workforce development is needed to ensure that health professionals can support the specific needs of SGM people. A 2009–2010 survey of U.S. and Canadian medical schools found that students received a median of 5 hours of SGM-related medical education and that 33% of schools provided no SGM-related clinical training. There are still no explicit requirements from the Liaison Committee on Medical Education or the Accreditation Council for Graduate Medical Education for including SGM specific health care topics in curricula. A recent study of residents in 120 U.S. internal-medicine programs revealed mean scores of 50 to 52% on a baseline assessment evaluating foundational knowledge of SGM health.
Medical schools and residency programs could establish competencies and introduce SGM health curricula that are developed, reviewed, and delivered by SGM health experts. Faculty can leverage training resources curated by organizations focused on SGM health, such as the National LGBTQIA+ Health Education Center at the Fenway Institute. Integrated content and practical experiences could be woven throughout core curricula to expand training that has historically been limited to electives and extracurricular initiatives.
Finally, physicians and their professional organizations can advocate against harmful legislation and for protective policies addressing the upstream political and social determinants of SGM health. Despite recent progress, explicit and broad protections based on SOGI are not common features of federal laws; instead, protections depend heavily on heterogeneous state- and municipal-level policies. Twenty-two states still permit conversion therapy for SGM adolescents, and only 23 states and Washington, D.C., have prohibited antiSGM bullying in schools, despite the connection of conversion therapy and bullying with psychological distress and suicidality.
Policies affirming fundamental rights have been shown to ease minority stress among SGM people. For example, quasi-experimental analyses found that the implementation of marriage equality significantly reduced suicidality among SGM adolescents and mental health visits among SGM adults. Federal legislation is needed to provide broad and clear protections for these populations; one such bill is the Equality Act, which would amend the 1964 Civil Rights Act to explicitly prohibit SOGI-based discrimination. Researchers can continue to investigate the health consequences of anti-SGM legislation and the potential benefits of protective policies and interventions.
As policymakers endanger health and access to care among SGM communities, we believe the health care sector should rededicate itself to supporting health equity for these populations. The Triple Aim offers providers, payers, researchers, and policymakers a common set of goals for protecting the health of SGM populations. The health care sector can commit to equitable resource allocation, care experiences, and health outcomes for people of all sexual orientations and gender identities.
Disclosure forms provided by the authors are available at NEJM.org. From Harvard Medical School (M.L., S.S., A.S.K.), the Fenway Institute, Fenway Health (A.S.K.), and the Department of Psychiatry, Massachusetts General Hospital (A.S.K.) — all in Boston. Mr. Liu and Mr. Sandhu contributed equally to this article. This article was published on July 23, 2022, at NEJM.org.