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A recent tragic case involving informed consent obtained from parents with limited English proficiency led to a successful lawsuit against the hospital. The parents were told the risks of surgery for their child included kidney damage, but there was no interpreter in the room.
“The child ended up on dialysis for the rest of his life. The parents sued, and the hospital settled for $12 million in a matter of weeks,” says Thomas A. LaVeist, PhD, director of the Johns Hopkins Bloomberg School of Public Health’s Hopkins Center for Health Disparities Solutions. “This is a tragedy on so many levels — not only for the family, but also for the hospital, the surgeon, and the people served by the hospital,” says LaVeist.
Social justice is an obvious reason to care about health and inequalities. “But that’s not the only reason why this matters. There is a utilitarian argument as well,” LaVeist says. “It is expensive to pay out claims of that type or to have people be sicker than they should be.”
Eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion for the years 2003-2006, according to a 2011 study.1 “If we don’t get a handle on health disparities, the implications are far bigger than social justice,” says LaVeist, the study’s lead author.
Clearly, more is being done now to address disparities, says Augustus A. White, III, MD, PhD, director of the Culturally Competent Care Education Program at Harvard Medical School in Boston. White is author of Seeing Patients: Unconscious Bias in Health Care. “So in that sense, there’s progress, but not in the sense of epidemiological studies that show disparities that were once noted are gone,” he says.
Under the Affordable Care Act (ACA), adds White, “more people are insured. That’s an important issue, because it means people are likely to have some kind of care.” Also, the National Center on Minority Health and Health Disparities, created in 2000, was re-designated as the National Institute on Minority Health and Health Disparities under the ACA. “So it has more clout, and hopefully will be more effective in diminishing disparities,” says White.
However, some have little confidence that the ACA will lead to a decrease in health disparities. Those skeptics include Cynthia Jones, PhD, associate professor of philosophy and director of the Pan American Collaboration for Ethics in the Professions at The University of Texas — Pan American in Edinburg. “Health disparities are the result of a complex tangle of factors, and despite decades of attention and research, we have yet to see movement in these disparities,” Jones says. “Dumping more money into high-cost care is unlikely to affect change.”
Reducing disparities is “an extremely complex issue,” says White. “Healthcare itself is so complex, with many variables: policies, politics, human behavior and technology. All of those things are very formidable problems.”
There is an obligation to do whatever you can to diminish healthcare disparities, says White. This obligation includes approaching hospital leaders.
“Ask CEOs and chiefs of services if there is a place for some specific institutional engagement on disparities,” he says. “The issue is it’s not ethical to penalize people for being in some particular group by providing care that is less good.”
To address healthcare disparities, consider doing the following:
• Train healthcare providers in communication methods that increase trust and lead to increased health literacy of the patients.
“Historical inequities have resulted in lack of trust, which can impact health outcomes,” says Jones. “Providers can attempt to mitigate trust issues through stressing culturally competent care.”
• Include questions about disparities in patient satisfaction surveys.
“People are trying to explore ways to provide feedback to physicians, so they can learn if they are thought to be culturally competent,” says White. Physicians with poor feedback can obtain training to improve their cultural competence, he says.
• Help clinicians to be aware of their own biases.
Disparate care often occurs unintentionally. “Everyone has biases. The bias is only a problem if it impacts behavior,” says LaVeist. “Awareness might help people to check themselves.”
• Raise the issue of disparate care during committee meetings.
Committees can unknowingly make decisions that have a differential impact on patients based on their race, ethnicity, or income status. “Someone needs to be in a position to say, ‘What is the impact of this on the vulnerable populations that we serve?’” says LaVeist. “Often, there is no one making that observation.”
• Bring financial costs to the attention of leaders.
If healthcare facilities are viewed as unfriendly to minorities, this view will affect their market share negatively. “With the expansion of Medicaid comes a whole new market of paying customers who previously didn’t get care or got uncompensated care,” says LaVeist. “Why wouldn’t you want to get their business?”
1. LaVeist TA, Gaskin D, Richard P. Estimating the economic burden of racial health inequalities in the United States. Int J Health Serv 2011; 41(2):231-238.