Data reveal biases that exist in minority care

OMH conference examines causes, solutions

It’s a disturbing but indisputable fact: If you are a person of color in the United States, you are more likely to receive poorer health care.

Even when researchers evaluate their data and control for rates of insurance status, income, age, and severity of medical conditions, significant disparities still exist.

"Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable," Alan Nelson, MD, former president of the American Medical Association, now special advisor to the chief executive officer of the Ameri-can College of Physicians — American Society of Internal Medicine, told attendees at the Department of Health and Human Services (HHS) National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health, held July 10-12 in Washington, DC.

A 1999 study, published in the New England Journal of Medicine, followed several black and white actors playing patients in different health care facilities. In the study, physicians were significantly less likely to recommend cardiac catheterization for black females than for white females, white males, and black males.1

A similar study published in the Journal of General Internal Medicine found that male physicians prescribed twice the level of pain medication for white patients than black patients, while female physicians prescribed higher doses of pain medications for black than for white patients.2

Nelson chaired the committee that wrote the recent Institute of Medicine (IOM) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,3 which detailed evidence of unequal access to care unexplained by traditional socioeconomic factors. He addressed the summit, asking that participants be willing to look for solutions beyond just admitting that access is a problem.

"The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them," he continues.

At the summit, government officials, public and private health care providers, and policy experts urged cooperative efforts at rooting out the causes of the disparity and developing solutions at the local level.

"We have got to increase awareness of the public and of our providers, and certainly our policy-makers that our health care system in many respects reflects the rest of this society," says Marsha Lillie Blanton, DrPH, director of policy research and grant making for the Kaiser Foundation. "What we know has got to become what society knows."

DHHS launches three-point agenda

As part of its goal to eliminate racial and ethnic health care disparities by the year 2010, HHS is focusing its efforts in three major areas, says Ruben King-Shaw, deputy administrator and chief operating officer of the department’s Centers for Medicare & Medicaid Services (CMS). The three main goals are:

1. Improving access to health insurance. Health insurance is the most common way people are connected to the health care system, King-Shaw says, and the department wants to improve and shore up the third-party payer system.

"Without insurance, a person’s encounters with health care providers are few and far between," he states. "They lack the ability to access preventive services or wellness services or continuity of care or primary care, diagnostic tests and treatment and education. These things don’t happen when you are not connected to the health care system."

Uncompensated care provided to uninsured patients also is a very significant issue for health care providers, he acknowledges. Continuing to rely on hospitals to provide a safety net is not a workable solution.

"The provision of insurance is an answer, but making sure that those who do not have insurance have access to health care is another part of the answer," he adds.

King-Shaw also warns against the push in many states to abandon Medicare+Choice programs that place Medicare beneficiaries in structured managed care plans using private health plans.

"Medicare Plus Choice contractors are leaving these systems for a variety of reasons," he notes. "The thing here is that a disproportionate number of people of color, African-Americans, Hispanic-Americans, and Asian-Americans, in certain markets are members of the programs."

These plans may be their members’ only chance at access to prescription coverage, wellness, prevention and education services that would otherwise be too costly, he adds.

"When you hear that an HMO is leaving the program, that the program should be scrubbed and thrown away. When you hear it was a failure and not worth salvaging, remember the abandonment of this program means abandoning disproportionately African-, Asian- and Hispanic-Americans who are relying on these programs."

Everyone should admit that there are problems with Medicare and Medicaid managed care that need to be addressed, he says, but without abandoning those most in need.

2. Developing community health centers. Part of that solution will be to improve the health care delivery system by expanding community and rural health centers and primary care clinics.

3. Reduce cultural ignorance in the system. HHS has initiated partnerships with community organizations in several areas to develop clinically and linguistically appropriate services for different populations, King-Shaw says.

"This is not just a matter of making sure you can generate a document in a specific language, it is making sure that when you generate a document in English or Spanish or Cantonese or Mandarin, that the communication has integrity when it connects to the individual," he explains.

For example, the agency has partnered with organizations in the Asian and Pacific Islander communities in New York and Boston to reduce the incidence of hepatitis B and to improve rates of mammography screening. The partnerships have developed Chinese-language public service announcements, conducted focus groups, and funded outcomes research in local populations.

"We hope to go beyond just communicating better. We want to empower community-based organizations to not just impart information, but to take part in the delivery of health care services in the communities in which they live," he says.

Public-private partnerships needed

Public and private health providers must work together to create sufficient political will to eliminate racial and ethnic health disparities, added James Gavin, MD, PhD, president of the Morehouse School of Medicine in Atlanta.

He points to the success that private, nonprofit organizations and public health professionals have achieved with linking cigarette smoking and lung and heart disease. Doctors routinely warn patients about the risks of smoking. Insurance companies give discounted premiums to nonsmokers, and tobacco manufacturers have been held accountable for the health outcomes of people who use their products.

"Health promotion, disease prevention messages, and strategies to eliminate disparities face a daunting challenge when countered and resisted by the power of marketing and economic incentives of a well-established and profitable retail market enterprise," Gavin says. "We have seen some hard-nosed creative push back by the tobacco industry. Without the surrender of private industry in the interest of public health, both the successful integration of methods and strategies across the health care system to eliminate disparities will be severely compromised."

Good science, good intentions, and good will are wonderful, he adds, but "as currencies, they are routinely trumped by economic incentives and tax credits."

Lawmakers must be convinced to design legislation that gives appropriate incentives to schools, employers, and insurance plans to encourage them to support healthy lifestyles and preventive medicine strategies.

Managed care organizations must be convinced of the benefit of designing cost-effective strategies for achieving and maintaining good health behaviors among their members. And community and faith-based organizations must participate in partnerships with health initiatives to "mold, shape, and inspire" the public’s will to change.

Health care providers must use their considerable power to lobby legislators in support of policies that end racial and ethnic discrimination, adds Robert K. Ross, MD, president and CEO of the California Endowment, a nonprofit health foundation that funds health improvement initiatives for Californians.

"The issue of disparity is not on the Top 10 list, or the Top 20 list. It’s not even on the Top 50 list of items that most elected officials are thinking that they are in a position where they must act," Ross says. "They are not at a point where they believe there is a political price to pay for failing to act."

In fact, surveys have shown that a substantial portion of the general public is uninformed about barriers of access to health care, says Lillie Blanton.

"Perceptions are important because they influence policy-makers and the public’s willingness to take action," she says.

A national survey of 4,000 adults found that the public has a marginal, at best, understanding of the disparities. And, there are significant differences in the perception of problems between whites and minorities.

"The survey found that the majority of whites perceive that African-Americans and Latinos get the same quality of care as whites," she says.

"Not surprisingly, that is not the view of most African-Americans or Latinos," she says. "When people were asked how often they think our health care system treats people unfairly based on language or race or ethnicity, you see closer agreement among the racial groups [about the existence of discrimination], but you still see sizeable percentages of people who don’t perceive that language, race or ethnicity affects their care."

For African-Americans and Hispanic-Americans surveyed, the most important health care issue was the high cost of insurance and of medical care, followed by a concern about the availability of providers, she notes.

Although research has shown some levels of discrimination exist regardless of income status or insurance coverage, members of minority populations perceive themselves at a disadvantage because of race, but also recognize the economic factors, she says.

"It is not as if in our efforts to change we can focus on one issue to the exclusion of others," she concludes.

References

1. Schwartz LM, Woloshin S, Welch HG. Misunderstandings about the effects of race and sex on physicians’ referrals for cardiac catheterization. N Engl J Med 1999; 340:618-626.

2. Weisse CS, Sorum PC, Sanders KN, et al. Do gender and race affect decisions about pain management? J Gen Intern Med 2001; 16:211-217.

3. Institute of Medicine. Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, Editors, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002. Accessed on-line at: www.nap.edu/catalog/10260.html.