Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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Consistent with the charge, the study committee focused part of its analysis on the clinical encounter itself, and found evidence that stereotyping, biases, and uncertainty on the part of healthcare providers can all contribute to unequal treatment. The conditions in which many clinical encounters take place- characterized by high time pressure, cognitive complexity, and pressures for costcontainment may enhance the likelihood that these processes will result in care poorly matched to minority patients' needs.
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Cross-cultural curricula should be integrated early into the training offuture healthcare providers, and practical, case-based, rigorously evaluated training should persist through practitioner continuing education programs. Finally, collection, reporting, and monitoring of patient care data by health plans and federal and state Mayors should be encouraged as a means to assess progress in eliminating disparities, to evaluate intervention efforts, and to assess potential civil rights violations.
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Defining Racial and Ethnic Healthcare Disparities The study committee defines disparities in healthcare as racial or ethnic differences in the quality of healthcare that are not due to access
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/ Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and Legal and Regulatory Climate Discrimination: Biases, Stereotyping, and Uncertainty Disparity FIGURE S-1 Differences, disparities, and discrimination: Populations with equal access to healthcare. SOURCE: Gomes and McGuire, 2001.
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Further, racial disparities in receipt of coronary revascularization procedures are associated with higher mortality among African Americans (Peterson et al., 1997~. Healthcare disparities are also found in other disease areas.
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African Americans, Hispanics, American Indians, and Pacific Islanders, and some AsianAmerican subgroups are disproportionately represented in the lower socioeconomic ranks, in lower quality schools, and in poorer-paying jobs. These disparities can be traced to many factors, including historic patterns of legalized segregation and discrimination.
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However, racial and ethnic differences in patient preferences and care-seeking behaviors and attitudes are unlikely to be major sources of healthcare disparities. For example, while minority patients have been found to refuse recommended treatment more often than whites, differences in refusal rates are small and have not fully accounted for racial and ethnic disparities in receipt of treatments (Hannan et al., 1999; Ayanian et al., 1999~.
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Further, as noted above, the majority of studies document disparities in healthcare services and disease areas when interventions are equally effective across population groups making the "racial differences" hypothesis an unlikely explanation for observed disparities in care. Finding 4-2: A small number of studies suggest that racial and ethnic minority patients are more likely than white patients to refuse treatment.
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Care Process-Level Variables: The Role of Bias, Stereotyping, Uncertainty Three mechanisms might be operative in healthcare disparities from the provider's side of the exchange: bias (or prejudice) against minorities; greater clinical uncertainty when interacting with minority patients; and beliefs (or stereotypes)
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Healthcare Provider Prejudice or Bias Prejudice is defined in psychology as an unjustified negative attitude based on a person's group membership (Dovidio et al., 1996~. Survey research suggests that among white Americans, prejudicial attitudes toward minorities remain more common than not, as over half to threequarters believe that relative to whites, minorities particularly African Americans are less intelligent, more prone to violence, and prefer to live off of welfare (Bobo, 2001~.
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Medical Decisions Under Time Pressure with Limited Information Studies suggest that several characteristics of the clinical encounter increase the likelihood that stereotypes, prejudice, or uncertainly may influence the quality of care for minorities (van Ryn, 2002~. In the process of care, health professionals must come to judgments about patients' conditions and make decisions about treatment, often without complete and accurate information.
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Patient Response: Mistrust and Refusal As noted above, the responses of racial and ethnic minority patients to healthcare providers are also a potential source of disparities. Little research has been conducted as to how patients may influence the clinical encounter.
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In addition, having a consistent relationship with a primary care provider may help to address minority patient mistrust of healthcare systems and providers, particularly if the relationship is with a provider who is able to bridge cultural and linguistic gaps (LaViest, Nickerson, and Bowie, 2000~. Minority patients, however, are less likely to enjoy a consistent relationship with a provider, even when insured at the same levels as white patients (Lillie-Blanton, Martinez, and Salganicoff, 2001~.
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To one extent or another, the various bills debated would all extend protections to enrollees in private managed care organizations, providing avenues for appeal of care denial decisions, improving access to specialty care, requiring health plans to disclose information about coverage, banning physician "gag" clauses, and providing other legal remedies to resolve disputes. Publicly funded health plans, however, are not addressed in these legislative proposals.
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Evidence-Based Cost Control In the current era of continually escalating healthcare costs, cost containment is an important goal of all health systems. To the extent possible, however, medical limit setting by health plans should be based on evidence of effectiveness.
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Recommendation 5-6: Promote the consistency and equity of care through the use of evidence-based guidelines. Financial Incentives in Healthcare Financial factors, such as capitation and health plan incentives to providers to practice frugally, can pose greater barriers to racial and ethnic minority patients than to white patients, even among patients insured at the same level.
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Recommendation 5-9: Support the use of interpretation services where community need exists. Community Health Workers Community health workers often termed lay health advisors, neighborhood workers, indigenous health workers, health aides, consejera, or promotora fulfill multiple functions in helping to improve access to healthcare.
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Multidisciplinary Teams Research demonstrates that multidisciplinary team approaches including physicians, nurses, dietitians, and social workers, among otherscan effectively optimize patient care. This effect is found in randomized controlled studies of patients with coronary heart disease, hypertension, and other diseases, and has extended to strategies for reducing risk behaviors and conditions such as smoking, sedentary lifestyle and obesity (Hill and Miller, 1996~.
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population, the development and implementation of training programs for healthcare providers offers promise as a key intervention strategy in reducing healthcare disparities. As a result, cross-cultural education programs have been developed to enhance health professionals' awareness of how cultural and social factors influence healthcare, while providing methods to obtain, negotiate and manage this information clinically once it is obtained.
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These challenges should be addressed to realize the potential of cross-cultural education strategies. Recommendation 6-1: Integrate cross-cultural education into the training of all current and future health professionals.
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Unfortunately, standardized data on racial and ethnic differences in care are generally unavailable. Federal and state-supported data collection
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More research is needed, for example, to understand the extent of disparities in care faced by Asian-American, Pacific-Islander, American Indian and Alaska Native, and Hispanic populations, and to better understand and surmount barriers to research on healthcare disparities, including those related to ethical issues in data collection.
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(1996~. Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction.
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(2000~. Ethnic and racial differences in longterm survival from hospitalization for HIV infection.
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(1997~. Recruitment and training issues from selected lay health advisor programs among African Americans: A 20-year perspective.
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(2001~. Racial differences in cardiac revascularization rates: Does "overuse" explain higher rates among white patients?
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(2001~. Funding Federal Civil Rights Enforcement: 2000 and Beyond.
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The committee recognizes that patients' preferences and clinicians' presentation of clinical information and alternatives influence each other, but found separation of the two to be analytically useful. 2 Consistent with the OMB classification scheme, the terms "African American" and "black" are used interchangeably throughout this report, as are the terms "Hispanic" and "Latino."
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