Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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3. Assessing Potential Sources of Racial and Ethnic Disparities in Care: Patient-and-System-Level Factors
3. Assessing Potential Sources of Racial and Ethnic Disparities in Care: Patient-and-System-Level Factors
Pages 125-159
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The chapter then presents a review of empirical literature that raises hypotheses regarding potential sources of racial and ethnic disparities in 125
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A MODEL: SOURCES OF HEALTHCARE DISPARITIES The Role of Clinical Discretion An integrated model of how racial and ethnic disparities in care emerge is presented in Figure 3-1. According to this model, patients present to healthcare providers with varied healthcare needs, expectations, and preferences, some of which are socio-culturally determined.
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Three sets of actors possess and exercise discretion: clinical caretakers, utilization managers remote from the bedside, and patients themselves. Patients' medical histories, physical exam findings, and diagnostic test results often present a level of uncertainty to physicians, and patients vary enormously in their help-seeking behavior, ways of presenting their symptoms and histories, and responses to medical recommendations (Bursztajn, 1990~.
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In and of itself, the discretion exercised by patients, providers, and utilization managers does not produce racial and ethnic disparities in healthcare. In most cases, patients and providers are able to work together in an iterative process to match patients' needs with appropriate treatment, regardless of race or ethnicity.
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Many clinical and laboratory data are likewise open to differing clinical interpretations by physicians with varying conceptual frameworks, perceptions, and biases. As will be discussed in the next chapter, it is reasonable to speculate that the resulting diagnostic subjectivity could permit clinical uncertainty, racial and ethnic biases, and stereotypes to influence the process and outcomes of clinical evaluation, resulting in racial and ethnic disparities in medical diagnosis.
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Utilization Managers as Discretionary Actors: Uncertainty at a Distance Variation and subjectivity in healthcare practice may also emerge at the level of health systems, particularly in managed care arrangements where utilization managers are charged with authorizing physicians' and patients' requests for reimbursement for services. Except where contractually bound by clinical practice protocols, utilization managers evaluate the necessity of claims from among a range of diagnostic and therapeutic alternatives acceptable within one or another subset of the medical community.
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notes, "For many African Americans, doubts about the trustworthiness of physicians and healthcare institutions spring from collective memory of the Tuskeegee experiments (Brandt, 2000) and other abuses of black patients by largely white health professionals (Randall, 1996; King, 1998~.
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, for example, found that African-American patients with African-American healthcare providers were more likely than those with non-minority providers to rate their physicians as excellent in providing healthcare, in treating them with respect, in explaining their medical problems, in listening to their concerns, and in being accessible. Hispanic patients who received care from Hispanic physicians did not rate their physicians as significantly better than Hispanic patients with non-Hispanic healthcare providers, but were more likely to be satisfied with their overall healthcare.
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After adjusting for patients' age, sex, marital status, income, health insurance status, and whether the respondent reported having a choice in physician, AfricanAmerican patients in race-concordant relationships were found to report higher satisfaction than African Americans in race-discordant relationships. Further, Hispanic patients in race-concordant relationships reported greater satisfaction than patients from other racial and ethnic groups in similarly concordant relationships.
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The authors performed a retrospective analysis of data obtained from a sample of Medicare patients hospitalized with acute myocardial infarction (MI) to determine whether racial differences in rates of cardiac catheterization were related to the race of attending physician.
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Minority Patient Mistrust and Experiences of Discrimination Some racial and ethnic minorities express greater levels of mistrust of healthcare providers and the medical establishment than white Americans, citing breeches of trust that have previously occurred between minorities and the scientific and medical communities (Swanson and Ward, 1995~. In addition, survey research generally indicates that ethnic minority patients perceive higher levels of racial discrimination in healthcare settings than non-minorities.
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, researchers found that nearly one-third of African Americans report having experienced discrimination at some point in their lifetimes when seeking healthcare, and 16% reported such experiences in the past year. More than onefifth of Hispanic patients reported similar experiences of discrimination in healthcare settings at any point in their lives, and between 7% and 19% of Asian-American subgroups reported such experiences.
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(1997) found that patient refusal of recommended cardiovascular procedures could not explain racial differences in "necessary" revascularization procedure rates.
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(2001) and other researchers speculate that racial differences in clinical characteristics may contraindicate the use of the same therapeutic procedures at similar rates in both African-American and white patients.
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Overuse of Clinical Services by White Patients Several researchers have suggested that racial and ethnic disparities in care may arise in part from the overuse of services among white patients, rather than differences in service utilization arising from clinical necessity. White patients enjoy generally higher levels of education and may have greater access to and means of gathering information about their presenting concerns and possible diagnostic and treatment options.
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The investigators followed 12,402 patients seen at Duke University Medical Center, and found that African Americans were 13% less likely than whites to undergo angioplasty and 32% less likely to undergo CABG. Racial differences in procedure rates were more marked among patients with severe disease.
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Finally, legal and regulatory policy with regard to healthcare can create a context in which healthcare disparities are not tolerated or implicitly accepted. These potential influences on the quality of care for racial and ethnic minority patients are discussed below, along with supporting evidence.
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Interpretation in healthcare settings has commonly been provided in one of several ways. Professional interpretation, using formally trained interpreters who demonstrate proficiency in mediating communication between languages and an understanding of medical terminology, remains rare.
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Revascularization procedures were deemed clinically necessary for all 631 patients, according to RAND criteria. The authors found no significant racial differences in rates of revascularization procedures among AfricanAmerican patients, (72%)
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After controlling for the proportion of elderly persons at the census-block level and for crime rates at the precinct level, the authors found that only 25% of pharmacies in predominantly non-white neighborhoods (those in which less than 40% of residents are white) had sufficient opioid supplies to treat patients in severe pain.
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Physicians' subsequent assessments and recommendations may therefore be based on incomplete information, or can be influenced by assumptions or unconscious stereotypes and biases, according to the authors. Patients' acceptance of physician recommendations also plays a minor role in racial differences in referral rates, as minority patients may refuse referral for invasive testing at higher rates than whites, and physicians may not have the time or interest in discussing patients' concerns or questions about unfamiliar procedures (see earlier
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, however, assessed minority physicians' experiences in both obtaining referrals for their patients to specialists and gaining hospital admissions. As noted earlier, racial and ethnic minority physicians are disproportionately more likely to serve minority patients, and therefore play a key role in enhancing access to care for minority populations.
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Significantly, much of the research on racial and ethnic disparities in healthcare cited in Chapter 1 controls for insurance status at only a crude level (e.g., insured versus uninsured, privately insured versus publicly insured, etc.) , and has not adequately controlled for variations in levels of insurance coverage.
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(1997) , for example, found no racial differences in rates of catheterization or revascularization among more than 1,400 military patients seeking care for acute myocardial infarction.
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among the military population. In addition, a recent study of VA systems found modest racial differences in mortality rates among African-American and white patients admitted for pneumonia, angina, congestive heart failure, chronic obstructive pulmonary disease, diabetes, or chronic renal failure, but these differences suggested better survival rates for minority patients (The et al., 2001~.
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found no overall racial differences in recommendation for revascularization. After adjusting for patients' age, co-morbidities, location and number of coronary stenoses, left ventricular function, and previous CABG, the authors found that white patients were more likely to undergo CABG and African-American patients were slightly (but not significantly)
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In many other areas, however, managed care has introduced new institutional dynamics that may enhance the conditions in which racial and ethnic disparities in healthcare can occur. Utilization review and practice guidelines, for example, may be used by some managed care organizations (MCOs)
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While more research must be conducted to fully test these hypotheses, evidence indicates that low-income and ethnic minority patients are less likely to have a regular provider, are more likely to be denied claims, and are less satisfied with many aspects of the care they receive in managed care settings. In a study of low-income African-American, Hispanic, and white patients enrolled in managed care and fee-for-service plans in four states, Leigh and colleagues found that for all three groups, those enrolled in managed care plans were less likely to have a regular provider than those enrolled in fee-for-service plans (Leigh, Lillie-Blanton, Martinez, and Collins, 1999~.
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Finally, some of the most significant support for the hypothesis that managed care may pose greater barriers to care for racial and ethnic minorities than whites is provided by Tai-Seale and colleagues (Tai-Seale, Freund, and LoSasso, 2001~. Using a "natural experiment," the authors assessed the differential effects of mandatory enrollment in managed care plans on use of clinical services by African-American and white Medicaid beneficiaries.
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107~. As noted above, racial and ethnic minority patients are less likely to be seen by a private physician, or to have a regular primary care provider, even when insured at the same level as whites (Lillie-Blanton et al., 2001~.
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Its application to the problem of healthcare discrimination, however, has been limited. In theory, medical malpractice law prescribes a unitary level of care, regardless of health insurance status or ability to pay.
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Even smaller proportions yield monetary settlements or judgments, and poor people and members of disadvantaged minority groups are less likely than other Americans to sue their doctors (Burstin et al., 1993~. Medical malpractice law is therefore of weak utility as a mechanism to address racial and ethnic discrimination in healthcare.
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Discriminatory practices such as denial of admitting privileges to African-American physicians,3 refusal of admission to patients lacking attending physicians with staff privileges, high prepayment requirements for black patients, and discriminatory routing of ambulances continued in some instances (Smith, 1999~. In these cases, the DHHS Office for Civil Rights (OCR)
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a powerful civil rights enforcement tool, applicable not only to racial disparities in the care provided to Medicare patients but also to disparate treatment of non-Medicare patients by physicians who accept Medicare. Given that most physicians accept Medicare, and given their important role as key decisionmakers with respect to use of hospital resources and services, extending the reach of Title VI to Medicare coverage of physician services would subject most of the private healthcare sector to Title VI enforcement.
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Finding 3-1: Many sources including health systems, healthcare providers, patients, and utilization managers may contribute to racial and ethnic disparities in healthcare. Evidence suggests that several sources may contribute to healthcare disparities, including healthcare providers, patients, utilization managers and healthcare systems.
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