Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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, 44, 46, 426-428, 431 Administrative choices in the design of managed care systems, 691-693 in establishing conditions of participation and quality of care management, 690-691 in separate SCHIP programs, 689-690 African Americans, 2, 34, 84-85, 278, 475477. See also Blacks defined, 32n, 34 and the "over-diagnosis" of schizophrenia, 612-613 739 African Moors, 498 Agassiz, Louis, 501 Age-adjusted death rates for all causes of death by race and Hispanic origin, 82 for selected causes of death by race and Hispanic origin, 83 Agency for Healthcare Research and Quality (AHRQJ, 219, 223, 226, 235, 243, 386, 420, 659, 711 Assessment of Quality Improvement Strategies in Health Care, 386 Measures of Quality of Care for Vulnerable Populations, 386 Translating Research into Practice, 386 Understanding and Eliminating Minority Health Disparities Initiative, 386 AHRQ.
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, 121, 421 Assumptions about racial and ethnic disparities in healthcare, 3-4, 3035 INDEX Asthma, 62-63, 296-297 Attitude of healthcare providers, 400401 Australian Aboriginal, defined, 474 Availability of services, 143-144 Aversive racism, 494, 614-616 Awareness of racial and ethnic differences in healthcare increasing among healthcare providers, 6, 20, 124 increasing among the general public and key stakeholders, 6, 20,124 AZT medication, 436 B Bakke decision, 121 Balanced Budget Act of 1997, 683, 689n Barriers for immigrants, 660 Bayer Institute, 196 Bayesian physicians, 167-168 Becker, Howard, 599 2002 Behavior Risk Factor Surveillance System, 387-388 Bernier, Franc5Ois, 499 BIA. See Bureau of Indian Affairs Bias defined, 522 of efficacy, 603-604 in physician decision-making, 632-637 in social stereotypes and attitudes, 169171 Bill of Rights, 459 Biological differences, that may justify differences in receipt of care, 138139 Biometric testing, 504 Blacks, 34, 475477.
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Program, 387 National Program of Cancer Registries, 387 National Training Center, 387 prostate cancer screening behaviors, 387 Racial and Ethnic Approaches to Community Health, 386-387 Centers for Medicare and Medicaid Services (CMS) , 222, 224, 388 Excellence Centers to Eliminate Ethnic / Racial Disparities, 388 Reducing Health Care Disparities National Project, 388 Centers of Excellence, 386, 391 Cerebrovascular disease, 57-58, 328-331 Cesarean deliveries, 67 Changes in concepts of race and ethnicity, 490496 in the ethnicity and race of medical students, physicians, nurses, and healthcare staff, 621 in the healthcare arena, 534-535 CHCs.
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See Contract Health Service Cincinnati Children's Hospital Center, 197 Civil Rights Act, 157, 188, 221, 507, 628-631, 668, 679 Title VI, 157, 159, 188, 192, 221, 628-631, 637-641, 668, 679 Title VII, 631 Civil rights dimension of racial and ethnic disparities in healthcare, 626-663 defining discrimination, 629-632 discrimination as a root cause of disparities, 632-649 using civil rights strategies to assist in eliminating racial and ethnic disparities, 649-663 Civil Rights Division, 654 Civil rights enforcement, 15, 187-188 Civil Rights era in healthcare, 506 Civil Rights Movements, 505 Civil rights strategies developing a comprehensive language access agenda, 657-660 developing capacity and infrastructure to address critical civil rights questions in managed care, 662 fixing the Sandoval decision, 661-662 identifying and eliminating other barriers for immigrants, 660 mandating the collection of data on race, ethnicity, and language of preference, 650-655 performing a civil rights self-assessment, 662-663 preventing discrimination through education of providers and patients, 660-661 strengthening the federal, state, and private healthcare, 655-657 using to assist in eliminating racial and ethnic disparities, 649-663 Civil War, 471, 501-502 discrimination during, 103 INDEX CLAS. See Culturally and linguistically appropriate services, standards for healthcare Class, defined, 522 Clinical caretakers as discretionary actors, 128-130 Clinical decision-making and the roles of stereotyping, uncertainty, and bias, 236-237 Clinical discretion, 125-130 clinical caretakers as discretionary actors, 128-130 patient as discretionary actor, 128 subjectivity and uncertainty, 128-130 subjectivity and variability, 128 utilization managers as discretionary actors, 130 Clinical encounters, 160-179 healthcare provider prejudice or bias, 162-174 medical decisions under time pressure with limited information, 161-162 mistrust and refusal, 174-175 patient response, 174-175 Clinical uncertainty, 9, 167-169 Clinician "bias," 611-616 Clinton, William, 626, 677, 692, 705 "Closing the Health Gap" campaign, 123 CMS.
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, 419 Cost containment strategies, 700-706 demand-side approaches, 701-702, 706712 (61~1~. see (cardiopulmonary resuscitation Criminal justice, racial discrimination in, 100-101 Criteria for literature review, 4041 ranking of studies, 41 review papers, 41 search keywords, 40 "threshold" criteria, 40 Critical analysis of the culture of medicine, 620-621 Cross-cultural approach, 206-207 Cross-cultural communication, links to racial/ethnic disparities in healthcare, 200-201 Cross-cultural curricula, in undergraduate medical education, 202 Cross-cultural education challenges and opportunities, 211-212 cultural sensitivity/awareness approach, 203-204 developing the field, 211 evaluation, 209-211 focus on attitudes, 203-204 focus on knowledge, 204-206 focus on skills, 206-207 foundation and emergence of, 201-203 in the health professions, 19-20, 199-214 improving healthcare professionals' ability to provide quality care, 214 multicultural/categorical approach, 204206 provider perspectives, 211 teaching methods and opportunities, 207-209 in the training of health professionals, 214 Cross Cultural Health Care Program (CCHCP)
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, 225-226 commissioned papers, 273 Consumer Assessment of Health Plans Survey (CAMPS) , 223 focus groups and roundtable discussions, 278, 284 Health Plan Employer Data and Information Set (HEDIS)
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See U.S. Department of Health and Human Services Diabetes, 64, 336-337 Diagnoses cancer, 431433 coronary artery disease, 425431 general medical and surgical care, 422425 HIV/AIDS, 437439 implications for change, 442444 improper, 397-398 overall pattern of evidence, 439440 racial and ethnic disparities in care, 441442 renal disease and kidney transplantation, 435437 review of the evidence and a consideration of causes, 417454 stroke, 434435 Diagnosis-related groups (DRGs)
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health disparities and Medicare and Medicaid administration, 681-693 health problems and long-term care needs of minority and nonminority individuals, 671 issues in the design, structure, and administration of, 664-698 overview, 667-673 poverty rates among minority and nonminority individuals, 672 racial and ethnic minority Americans as a share of the elderly population, 671 supplemental insurance coverage among minority and non-minority Medicare beneficiaries, 672 Federal-level and other initiatives to address racial and ethnic disparities in healthcare, 235, 384391 Cambridge Health Alliance, 391 Department of Health and Human Services (DHHS) , 384-391 Department of Veterans Affairs, 391 Executive Office of the President, 384 Federal policies and practices, assessment of, 220-221 Federal Register, 640, 651 Federal role in racial, ethnic, and primary language health data, 219-223 Federally Qualified Health Center, 536 Fee-for-service health systems, 75, 705
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, 222-223, 389, 418, 420, 436, 536-537 database of, 423 Health deficit, defined, 525 Health disparities and Medicare and Medicaid administration, 548, 681-693 choices in establishing conditions of participation and quality of care management, 690-691 choices in provider payment, 687-689 choices in setting eligibility standards and enrollment arrangements, 685-687 choices in the design of managed care systems, 691-693 concentration of poverty, in 100 largest U.S. cities, 688 conditions of physician participation, 683-684 issues underlying racial disparities, 684685 separate SCHIP programs, 689-690 Health insurance coverage.
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, 388389 Measuring Cultural Competence in Health Care Delivery Settings, 388 Oral Health Initiative, 389 Provider's Guide to Quality and Culture, 389 Health Security Act, 705 Health services, defined, 31 Health status of racial and ethnic minority populations, 81-83 age-adjusted death rates for all causes of death by race and Hispanic origin, 82 age-adjusted death rates for selected causes of death by race and Hispanic origin, 83 Health system interventions, 15-18, 188-196 community health workers, 17-18, 193195 evidence-based cost control, 15-16, 189190 financial incentives in healthcare, 16-17, 190-191 interpretation services, 17, 191-193 multidisciplinary teams, 195-196 Healthcare, defined, 31, 523 INDEX Healthcare disparities addressing through the training of healthcare professionals, 606-611 among non-African American minority groups, 240 improving research on, 242-243 sources of, 125-130 Healthcare dollars, 536-537 Healthcare environment, 80-124 brief history of legally segregated healthcare facilities, 103-108 contemporary defacto segregation, 103-108 health status of racial and ethnic minority populations, 81-83 healthcare professions workforce in minority and medically underserved communities, 114120 historical determinants of contemporary minority health professions workforce, 105-108 historical overview of healthcare delivery for racial and ethnic minority patients, 102-103 insurance status of racial and ethnic minority populations, 83-87 linguistic barriers of racial and ethnic minority populations, 87-90 participation of racial and ethnic minorities in health professions education, 120-123 racial attitudes and relations, 91-95 racial discrimination, 95-101 relationship to broader racial attitudes and discrimination, 6-7, 101-102 settings in which racial and ethnic minorities receive healthcare, 108114 Healthcare facilities, producing unique scores for, 229 Healthcare professions workforce in minority and medically underserved communities, 114120 demographics of healthcare providers, 114-116 impact of international medical graduates (IMGs) on the workforce in minority communities, 116-120 top 10 countries with highest proportion of medical graduates, 119
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, 421 Historical determinants, of contemporary minority health professions workforce, 105-108 Historical perspective, on inequities and bias, 496497 Historical thinking, 496 History of racial and ethnic disparities in healthcare, 102-103, 455-527 American Indians or Alaska Natives, 477-478, 528-534 American racial and ethnic relations, 458460 Asian Americans or Pacific Islanders, 478480 Blacks or African Americans (not of Hispanic origin) , 475-477 changing concepts of race and ethnicity, 490496 dynamics of the U.S.
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healthcare and health systems age of science and enlightenment, 499500 ancient origins, 497-498 Civil Rights era in healthcare, 506 Civil War, 501-502 Colonial, Republican, Jacksonian, and Antebellum periods, 501 early 20th century, 503-505 failed reform and corporate takeover, 508 Great Depression and World War II, 505 groundwork for civil rights in healthcare, 505-506 health system shedding some negative aspects of its past, 508-510 historical perspective on inequities and bias, 496497 Middle Ages, 498499 origins and evolution of, 496-510 Reconstruction, Gilded Age, and "Progressive" eras, 502-503 Renaissance, 499 retrenchment era in healthcare, 507-508 Initiative to Eliminate Racial and Ethnic Disparities in Health, 626 Institute for Urban Family Health, 634 Institute of Medicine (IOM) , 13, 15-16, 30, 32, 38, 184, 189-190, 203, 274-277, 279-280, 389, 455-457, 595 Committee on Understanding and Eliminating Racial and Ethnic Health Disparities, 508, 595 Crossing the Quality Chasm, 13, 15-16, 38, 184, 189-190 Measuring the Quality of Health Care, 31 Report on Primary Care, 203 Institutional discrimination in healthcare, 95, 402403
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whites, 86 Hispanic Americans, 87 probability of being uninsured by race and ethnicity, 83 sources of health insurance by race and ethnicity, 84 Integrated approaches to measuring disparities in healthcare, 227, 229231 accessibility of data sources, 229 applicable to multiple racial/ethnic groups, 229 longitudinality, 229 no confounding, 229 producing unique scores for individual healthcare facilities, 229 Integrated model of healthcare disparities, 127 Integrating cross-cultural education into training of all current and future health professionals, 20-21, 214 Intensive care units (ICUs) , 425 Intentional discrimination, 639-640 Interamerican College of Physician Surgeons, 390 Internalized racism, 494, 524 defined, 524 International medical graduates (IMGs)
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Department of Health and Human Services, standards for culturally and linguistically appropriate services, 182-183 Legally segregated healthcare facilities, brief history of, 103-108 Lenox Hill Hospital, 484 Libertarian theories, 725-726 Libertarian views of the relevance of causal explanations, 730-732 Life sciences, 496 defined, 524 Linguistic barriers of racial and ethnic minority populations, 87-90 American Indians and Alaska Natives 89 Asian Americans and Pacific Islanders (API) , 89-go INDEX healthcare providers, 89-90 Hispanics or Latinos, 88 linguistically isolated households, by race and ethnicity, 89 Linnaeus, Carl, 499 Literature review, 5-6, 38-77, 271, 273, 285383, 632-637 analgesia, 64-66, 290-295, 326-327 asthma, 62-63, 296-297 cancer, 52-57, 298-305 cardiovascular disease, 39, 42-52, 306325, 328-329 cerebrovascular disease, 57-58, 328-331 children's health services, 68-69, 330-335 control over key clinical characteristics, 380-383 criteria, 4041 diabetes, 64, 336-337 emergency services, 71-74, 336-339 eye care, 71-74, 338-341 gallbladder disease, 71-74, 340-341 HIV/AIDS, 61-62, 342-343 keywords, 285 maternal and infant health, 66-68, 344349 mental health services, 69-71, 348-353 other clinical and hospital-based services, 71-74 patient perceptions, 71-74, 358-359 peripheral vascular disease, 71-74, 352355 pharmacy services, 71-74, 352-355 physician perceptions, 71-74, 354-359 potential role of bias in physician decision-making, 632-637 potential role of discrimination in explaining racial and ethnic disparities in health, 637 radiographic services, 71-74, 360-361 rehabilitative services, 66, 360-363 renal transplantation, 58-60, 362-365 research needed, 22-23, 235-243 review papers, 41 use of services and procedures, 71-74, 364-377 vaccination, 71-74, 374-375 women's health services, 376-379 Loma Linda University, 387 L on g itu d in ality, 2 2 9 Lyell, Sir Charles, 501
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See Managed care organizations Measures of Quality of Care for Vulnerable Populations, 386 Measuring Cultural Competence in Health Care Delivery Settings, 388 Medicaid, 77, 84-85, 119, 141, 147, 185, 220, 222, 391, 535-539, 542, 546, 619, 629, 659-660, 664-670, 676, 681-687 applying for, 637, 648 legislation creating, 104, 118, 505, 507 payments per recipient by race, 680 reimbursements, 157 Medicaid and the State Children's Health Insurance Program, 673-681 health insurance status by race and ethnicity, 679-680 753 Medicaid payments per recipient by race, 680 Medicaid MCOs, 217 regulations for, 222 Medical decisions, under time pressure, with limited information, 11-12, 161-162 Medical Expenditure Panel Survey (MEPS) , 73, 110, 223-224 Household Component, 224 Insurance Component, 224 Medical Provider Component, 224 Nursing Home Component, 224 Medical graduates, top 10 countries with highest proportion of, 119 Medical "machine," 604-606 Medical Outcomes Study (MOS)
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See Massachusetts Medical Interpreter Association Model minority stereotype, defined, 524 Models for measuring disparities in healthcare, 226-232 "Health Accountability 36," 226-228 integrated approaches, 227, 229-231 reporting of racial and ethnic disparities using existing data sets, 231-232 Monitoring healthcare disparities, 241 Monitoring progress, toward elimination of healthcare disparities, 21-22, 234 Moon, Marilyn, 667, 694 Moral foundations, 724-729 Mortgage lending, racial discrimination in, 96 Morton, Samuel George, 501 MOS. See Medical Outcomes Study Mt.
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, 15, 157, 187, 192, 218, 385-386, 630-631, 638649, 656 Limited English Proficiency Guidelines, 695 Office of Economic Opportunity (OEO) , 531 Office of Indian Affairs, 530 Office of Management and Budget, 32, 227, 234, 384, 461, 463 Guidance on Aggregation and Allocation of Data on Race for Use in Civil Rights Monitoring and Enforcement, 384 Standards for the Classification of Federal Data on Race and Ethnicity, 32 Office of Minority Health (OMH)
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style and other aspects of communication, 572-574 correlates of communication, 557-558 INDEX evidence of race-concordance consequences for the communication process, 574 implications for physician training and patient activation to improve patient-physician communications within culturally diverse populations, 575-577 nature and consequences of broad normative expectations, bias, and racial stereotyping by providers and patients, 556-557 needed research, 577-579 physician role obligations and medicine's unwritten social contract, 556 relationship between communication style and patient satisfaction and health outcomes, 574-575 role and impact of patient sociodemographics on medical communication, 562-572 role of cross-cultural training for healthcare professionals, 579-580 role of physician sociodemographic characteristics on the medical dialogue, 558-564 scope of topic, 553-555 Patient sociodemographics age, 565-567 gender, 565 health status, 569-570 literacy, 570-572 race and ethnicity, 562-565 social class, 567-569 Patients appearance, 399 cost sharing by, 706-711 as discretionary actors, 128 economic/insurance status, 399-400 education and empowerment, 18-19,196198 perceptions, 71-74, 358-359 preferences, 131-135 protecting, 14-15, 186-187 refusal of recommended treatment, 136138 response by, 12, 174-175 role and impact on medical communication, 562-572
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See also Current Population Survey; Measures of Quality of Care for Vulnerable Populations defined, 31 elderly, 671 growing diversity of U.S., 181 health status of, 81-83 immigrant, 647-649 insurance status of, 83-87 nurses, 117 with equal access to healthcare, 4, 33 Positron tomography, 129 Postmodernism, 495n Poverty rates, among minority and nonminority individuals, 672 757 Practice arrangements, of minority physicians, 621 Pre-Columbian and North American development, 466-467 Preferences, defined, 4n Prejudice, defined, 524 "Prejudice-related conflict," 616 Prescription services, 73 Prichard, James Cowles, 501 Primary care visits, made to primary care delivery sites by health insurance payer and race/ethnicity, 113 Professional interpretation services, increasing linguistic diversity in the U.S. requires increase in, 193 Proficiency, limited, in English, 640-642 Program successes redressing imbalances in care, assessment of, 621 Prostate cancer screening behaviors, 387 Protease inhibitors (PI)
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758 North American health and health care, 466469 pre-Columbian and North American development, 466-467 perceptions of violence, involuntary commitment, and diagnosis of schizophrenia, 616-618 Race-discordant dyads, 574 Racial and Ethnic Approaches to Community Health (REACH) , 386-387 Racial and ethnic disparities in healthcare assessing potential sources of, 7-12 assumptions, 34, 30-35 background and history, 455-527 bias, stereotyping, prejudice, and clinical uncertainty on part of healthcare providers contributing to, 12, 19, 178 civil rights dimension of, 626-663 culture of medicine and, 594-625 data collection and monitoring, 21-22, 215-234, 460-464 defining, 34 diagnosis and treatment of, 417-454 ethical analysis of when and how they matter, 722-738 evidence of, 5-6, 38-77 existence and unacceptability of, 6, 19, 79 federal-level and other initiatives to address, 235, 384-391 focus group findings, 392405 global problem, 441442 health disparities and Medicare and Medicaid administration, 681-693 healthcare environment and its relation to, 80-124 impact of cost containment efforts on, 699-721 importance of, 36-38 interventions to eliminate, 13-20 many sources contributing to, 12, 19, 159 minority patients more likely than white patients to refuse treatment, 8, 19, 179 occurring in the context of broader historic and contemporary social and economic inequality, 6-7, 19, 123 patient-provider communication, 552593 INDEX populations with equal access to he althc are, 4 , 33 relationship of health status to, 35-36 relationship to broader racial attitudes and discrimination, 101-102 revised standards for the classification of federal data on race and ethnicity, 34 their documentation in the U.S., 487-489 Racial and ethnic minority groups defined, 32-33 share of the elderly population, 671 Racial attitudes discrimination in the United States, 6-7 relations, 91-95 Racial categories for federal data American Indian or Alaska Native, 34 Asian, 34 Black or African American, 34 Native Hawaiian or other Pacific Islander, 34 White, 34 Racial discrimination, 95-101 in criminal justice, 100-101 minority youth in the juvenile justice system, 100-101 defined, 95-96 in employment, 100 in housing, 96-100 in mortgage lending, 96 Racial groups defined, 525 hierarchies, 490493 Racial models, as tools for analysis and understanding, 493-495 Racial profiling, the importance of data collection, 654-655 Racism, 491 aversive, 494 competitive, 493 dominative, 494 ideological, 523 individual, 493 institutionalized, 494 internalized, 494, 524 paternalistic, 493 personally mediated, 494, 524 scientific, 501, 504, 525 societal, 493 Racism in Medicine: An Agenda for Change, 441
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racial and ethnic minorities among health professionals, 14, 20, 186 integrating cross-cultural education into training of all current and future health professionals, 20-21, 214 monitoring progress toward elimination of healthcare disparities, 21-22, 234 promoting the consistency and equity of care through the use of evidencebased guidelines, 16, 20, 189-190 providing greater resources to the U.S. DHHS Office for Civil Rights to enforce civil rights laws, 15, 20, 188 reporting racial and ethnic data by federally defined categories, 2122, 234 strengthening the stability of patientprovider relationships in publicly funded health plans, 14, 20, 185 structuring payment systems to ensure an adequate supply of services to minority patients, 17, 20, 190-191 supporting the use of community health workers, 18, 21, 195 supporting the use of interpretation services where community need exists, 17, 20, 193 Reconstruction, in Black health, 509
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See State Children's Health Insurance Program Schizophrenia, African Americans and the "over-diagnosis" of, 612-613 Schulman, Kevin, 635
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, 220, 223, 649, 668 "Enumeration at Birth" program, 649 Master Beneficiary Record database, 224 Social structural Egalitarian views of causality, brute luck and, 732-734 Societal racism, 493 Sociocultural thinking, 496 Socioeconomic status (SES) , 68, 75, 166-167, 286, 557-558, 595, 635 Sources of health insurance by race and ethnicity, 84 761 Sources of medical care, those having no usual, 109 Sources of racial and ethnic disparities in healthcare assessing potential, 7-12 clinical encounter, 160-179 clinical uncertainty, 9 healthcare provider prejudice or bias, 1011 healthcare systems-level factors, 8-9 implicit nature of stereotypes, 10 medical decisions under time pressure with limited information, 11-12 patient- and system-level factors, 125-159 patient-level variables, 7-8 patient response, 12 role of bias, stereotyping, and uncertainty, 9-12 Southwest Native American Cardiology Program, 389 Sowell, Thomas, 496 Spanish heritage, 480-481, 564 "Spanish Language and Cultural Competence Curriculum," 209 Special Programs Development Branch, 391 Specialized HIV/AIDS outreach and substance abuse treatment, 390 Spirit Catches You and You Fall Down, The, 605 SSA.
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(SHIRE) , 219-222 Sunshine Amendment, 654 Supplemental insurance coverage, among minority and non-minority Medicare beneficiaries, 672 Supplemental Security Income, 675 Supply-side approaches, 703-705, 712-718 capitation and DRGs, 713-715 cost containment and demand for clinical services, 154-155 health plan payments to primary care physicians, 704 health plan payments to specialists, 704 low physician fees, 712-713 supply, technology, and expenditure controls, 717-718 utilization review and practice guidelines, 716-717 Supreme Court.
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, 386 Treatment cancer, 431433 coronary artery disease, 425431 general medical and surgical care, 422425 HIV/AIDS, 437439 implications for change, 442444 improper, 397-398 overall pattern of evidence, 439440 racial and ethnic disparities in care, 441442 renal disease and kidney transplantation, 435437 review of the evidence and a consideration of causes, 417454 stroke, 434435 Triage scoring, 153 Tribal/consumer perspectives, 537-539 TRIP. See Translating Research into Practice Trujillo, Michael, 530 Tuskeegee Syphilis Study, 131, 205 U UCLA Center for Health Policy Research, 225 UCLA criteria, 48, 139 UCLA Medical Center, emergency department, 65 Underrepresented minority (URM)
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, 389390 Office for Civil Rights (OCR) , 15, 157, 187, 192, 218, 630-631, 638-649 Office of Minority Health (OMH)
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