Unequal Treatment: Understanding and Eliminating Racial and Ethnic Disparities in Healthcare

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• STUDY CHARGE
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• Assess the extent of racial and ethnic
  differences in healthcare that are not otherwise
  attributable to known factors such as access to
  care (e.g., ability to pay or insurance
  coverage)
• Evaluate potential sources of racial and ethnic
  disparities in healthcare, including the role of
  bias, discrimination, and stereotyping at the
  individual (provider and patient), institutional,
  and health system levels and,
• Provide recommendations regarding interventions
  to eliminate healthcare disparities.

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CAVEATS

• Access (e.g., insurance status, ability to pay
  for healthcare) is the most important predictor
  of the quality of healthcare across racial and
  ethnic groups
• It is difficult even artificial to separate
  access-related factors from social categories
  such as race and ethnicity
• The bulk of research on healthcare disparities
  has focused on black-white differences more
  research is needed to understand disparities
  among other racial and ethnic minority groups

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Differences, Disparities, and Discrimination
Populations with Equal Access to Health Care
Clinical Appropriateness and Need Patient
Preferences
Non-Minority
The Operation of Healthcare Systems and the
Legal and Regulatory Climate
Difference
Quality of Health Care
Minority
Disparity
Discrimination Biases and Prejudice,
Stereotyping, and Uncertainty
Populations with Equal Access to Health Care
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Evidence of Racial and Ethnic Disparities in
Healthcare

• Disparities consistently found across a wide
  range of disease areas and clinical services
• Disparities are found even when clinical factors,
  such as stage of disease presentation,
  co-morbidities, age, and severity of disease are
  taken into account
• Disparities are found across a range of clinical
  settings, including public and private hospitals,
  teaching and non-teaching hospitals, etc.
• Disparities in care are associated with higher
  mortality among minorities (e.g., Bach et al.,
  1999 Peterson et al., 1997 Bennett et al., 1995)

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Among Medicare Beneficiaries Enrolled in Managed
Care Plans, African Americans Receive Poorer
Quality of Care (Schneider et al., JAMA, March
13, 2002)
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Black and White Differences in Specialty
Procedure Utilization Among Medicare
Beneficiaries Age 65 and Older, 1993
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What are potential sources of disparities in care?

• Health systems-level factors financing,
  structure of care cultural and linguistic
  barriers
• Patient-level factors including patient
  preferences, refusal of treatment, poor
  adherence, biological differences
• Disparities arising from the clinical encounter

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Potential Sources of Racial and Ethnic Healthcare
Disparities Healthcare Systems-level Factors

• Cultural and linguistic barriers many
  non-English speaking patients report having
  difficulty accessing appropriate translation
  services
• Lack of stable relationships with primary care
  providers minority patients, even when insured
  at the same level as whites, are more likely to
  receive care in emergency rooms and have less
  access to private physicians
• Financial incentives to limit services may
  disproportionately and negatively affect
  minorities
• Fragmentation of healthcare financing and
  delivery

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Potential Sources of Racial and Ethnic Healthcare
Disparities Patient-level Factors

• Minority patients may be more likely to refuse
  recommended services, adhere poorly to treatment,
  and delay seeking care
• These may develop as a result of poor cultural
  match between patients and providers,
  misunderstanding of provider instructions, poor
  prior interactions with health care systems, lack
  of knowledge of how to best use services
• Patient level factors unlikely to be major
  sources of healthcare disparities

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Potential Sources of Racial and Ethnic Healthcare
Disparities - Disparities arising from the
clinical encounter

• The Core Paradox
• How could well-meaning and highly educated health
  professionals, working in their usual
  circumstances with diverse populations of
  patients, create a pattern of care that appears
  to be discriminatory?

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Disparities in the Clinical Encounter The Core
Paradox

• Possibilities examined bias (prejudice),
  uncertainty, stereotyping
• Bias no evidence suggests that providers are
  more likely than the general public to express
  biases, but some evidence suggests that
  unconscious biases may exist
• Uncertainty a plausible hypothesis,
  particularly when providers treat patients that
  are dissimilar in cultural or linguistic
  background
• Stereotyping evidence suggests that providers,
  like everyone else, use these cognitive
  shortcuts

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Disparities in the Clinical Encounter
Stereotyping A Definition

• Stereotyping can be defined as the process by
  which people use social categories (e.g. race,
  sex) in acquiring, processing, and recalling
  information about others.
• Stereotyping beliefs may serve important
  functions - organizing and simplifying complex
  situations and giving people greater confidence
  in their ability to understand, predict, and
  potentially control situations and people.

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Disparities in the Clinical Encounter
Stereotyping Risks

• Can exert powerful effects on thinking and
  actions at an implicit, unconscious level, even
  among well-meaning, well-educated persons who are
  not overtly biased.
• Can influence how information is processed and
  recalled.
• Can exert self-fulfilling effects, as patients
  behavior may be affected by providers overt or
  subtle attitudes and behaviors.

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Disparities in the Clinical Encounter
Stereotyping When Is It in Action?

• Situations characterized by time pressure,
  resource constraints, and high cognitive demand
  promote stereotyping due to the need for
  cognitive shortcuts and lack of full
  information.

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What is the Evidence that Physician Biases and
Stereotypes May Influence the Clinical Encounter?

• van Ryn and Burke (2000) - study conducted in
  actual clinical settings found that doctors are
  more likely to ascribe negative racial
  stereotypes to their minority patients. These
  stereotypes were ascribed to patients even when
  differences in minority and non-minority
  patients education, income, and personality
  characteristics were considered.
• Finucane and Carrese (1990) - Physicians more
  likely to make negative comments when discussing
  minority patients cases.

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What is the Evidence that Physician Biases and
Stereotypes may Influence the Clinical Encounter
(contd)?

• Rathore et al. (2000) found that medical
  students were more likely to evaluate a white
  male patient with symptoms of cardiac disease
  as having definite or probable angina,
  relative to a black female patient with
  objectively similar symptoms.
• Abreu (1999) found that mental health
  professionals and trainees were more likely to
  evaluate a hypothetical patient more negatively
  after being primed with words associated with
  African American stereotypes.

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• SUMMARY OF FINDINGS
• Racial and ethnic disparities in health care
  exist and, because they are associated with worse
  outcomes in many cases, are unacceptable.
• Racial and ethnic disparities in health care
  occur in the context of broader historic and
  contemporary social and economic inequality, and
  evidence of persistent racial and ethnic
  discrimination in many sectors of American life.
• Many sources including health systems, health
  care providers, patients, and utilization
  managers contribute to racial and ethnic
  disparities in health care.
•  

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• SUMMARY OF FINDINGS (Continued)
• Bias, stereotyping, prejudice, and clinical
  uncertainty on the part of healthcare providers
  may contribute to racial and ethnic disparities
  in healthcare.
• Racial and ethnic minority patients are more
  likely than white patients to refuse treatment,
  but differences in refusal rates are generally
  small, and minority patient refusal does not
  fully explain healthcare disparities.

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• SUMMARY OF RECOMMENDATIONS
• GENERAL RECOMMENDATION
• Increase awareness of racial and ethnic
  disparities in health care among the general
  public and key stakeholders, and increase health
  care providers awareness of disparities.
•  

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• LEGAL, REGULATORY, AND POLICY RECOMMENDATIONS
• Avoid fragmentation of health plans along
  socioeconomic lines, and take measures to
  strengthen the stability of patient-provider
  relationships in publicly funded health plans
• Increase the proportion of underrepresented U.S.
  racial and ethnic minorities among health
  professionals
• Apply the same managed care protections to
  publicly funded HMO enrollees that apply to
  private HMO enrollees
• Provide greater resources to the U.S. DHHS Office
  of Civil Rights to enforce civil rights laws.

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• HEALTH SYSTEMS INTERVENTIONS
• Promote the consistency and equity of care
  through the use of evidence-based guidelines
• Structure payment systems to ensure an adequate
  supply of services to minority patients, and
  limit provider incentives that may promote
  disparities
• Enhance patient-provider communication and trust
  by providing financial incentives for practices
  that reduce barriers and encourage evidence-based
  practice
• Promote the use of interpretation services where
  community need exists. The use of community
  health workers and multidisciplinary treatment
  and preventive care teams should also be
  supported.

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• EDUCATION
• Patient education programs should be implemented
  to increase patients knowledge of how to best
  access care and participate in treatment
  decisions.
• Integrate cross-cultural education into the
  training of all current and future health
  professionals.

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• DATA COLLECTION AND MONITORING
• Collect and report data on health care access and
  utilization by patients race, ethnicity,
  socioeconomic status, and where possible, primary
  language
• Include measures of racial and ethnic disparities
  in performance measurement
• Monitor progress toward the elimination of health
  care disparities
• Report racial and ethnic data by OMB categories,
  but use subpopulation groups where possible.

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• NEEDED RESEARCH
• Conduct further research to identify sources of
  racial and ethnic disparities and assess
  promising intervention strategies, and
• Conduct research on ethical issues and other
  barriers to eliminating disparities.