STUDY CHARGESTUDY CHARGE   Assess the extent of racial and ethnic Assess the extent of racial and ethnic

differences in healthcare that are not differences in healthcare that are not otherwise attributable to known factors such otherwise attributable to known factors such as access to care (e.g., ability to pay or as access to care (e.g., ability to pay or insurance coverage);insurance coverage);

Evaluate potential sources of racial and ethnic Evaluate potential sources of racial and ethnic disparities in healthcare, including the role of disparities in healthcare, including the role of bias, discrimination, and stereotyping at the bias, discrimination, and stereotyping at the individual (provider and patient), institutional, individual (provider and patient), institutional, and health system levels; and,and health system levels; and,

Provide recommendations regarding Provide recommendations regarding interventions to eliminate healthcare interventions to eliminate healthcare disparities.disparities.

Access (e.g., insurance status, ability to pay Access (e.g., insurance status, ability to pay for healthcare) is for healthcare) is thethe most important most important predictor of the quality of healthcare across predictor of the quality of healthcare across racial and ethnic groupsracial and ethnic groups

It is difficult – even artificial – to separate It is difficult – even artificial – to separate access-related factors from social access-related factors from social categories such as race and ethnicitycategories such as race and ethnicity

The bulk of research on healthcare The bulk of research on healthcare disparities has focused on black-white disparities has focused on black-white differences – more research is needed to differences – more research is needed to understand disparities among other racial understand disparities among other racial and ethnic minority groupsand ethnic minority groups

CAVEATSCAVEATS

Non

-Min

ori

ty

Min

orit

yDifference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and Regulatory Climate

Discrimination: Biases andPrejudice, Stereotyping, andUncertainty

Disparity

Qu

alit

y o

f H

eal t

h C

are

Differences, Disparities, and Differences, Disparities, and Discrimination: Populations with Discrimination: Populations with

Equal Access to Health CareEqual Access to Health Care

Populations with Equal Access to Health Care

Evidence of Racial and Ethnic Evidence of Racial and Ethnic Disparities in HealthcareDisparities in Healthcare

Disparities consistently found across a wide Disparities consistently found across a wide range of disease areas and clinical servicesrange of disease areas and clinical services

Disparities are found even when clinical Disparities are found even when clinical factors, such as stage of disease presentation, factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are co-morbidities, age, and severity of disease are taken into accounttaken into account

Disparities are found across a range of clinical Disparities are found across a range of clinical settings, including public and private hospitals, settings, including public and private hospitals, teaching and non-teaching hospitals, etc.teaching and non-teaching hospitals, etc.

Disparities in care are associated with higher Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1999; Peterson et al., 1997; Bennett et al., 1995)1995)

Among Medicare Beneficiaries Enrolled in Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et Receive Poorer Quality of Care (Schneider et al., al., JAMAJAMA, March 13, 2002), March 13, 2002)

20

30

40

50

60

70

80

Per

cent

Rec

eivi

ng S

ervi

ces

BreastScreening

Eye Exams BetaBlockers

Follow-up

Health Service

WhitesBlacks

Black and White Differences in Specialty Black and White Differences in Specialty Procedure Utilization Among Medicare Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993Beneficiaries Age 65 and Older, 1993

Black White Black-to-

White Ratio

Angioplasty (procedures per 1,000 beneficiaries per year)

2.5 5.4 0.46

Coronary Artery Bypass Graft Surgery (procedures per 1,000 beneficiaries per year)

1.9 4.8 0.40

Mammography (procedures per 100 women per year)

17.1 26.0 0.66

Hip Fracture Repair (procedures per 100 women per year)

2.9 7.0 0.42

Amputation of All or Part of Limb (procedures per 1,000 beneficiaries per year)

6.7 1.9 3.64

Bilateral Orchiectomy (procedures per 1,000 beneficiaries per year)

2.0 0.8 2.45

Source: Gornick et al., 1996

What are potential sources of What are potential sources of disparities in care?disparities in care?

Health systems-level factors – Health systems-level factors – financing, structure of care; financing, structure of care; cultural and linguistic barrierscultural and linguistic barriers

Patient-level factors – including Patient-level factors – including patient preferences, refusal of patient preferences, refusal of treatment, poor adherence, treatment, poor adherence, biological differencesbiological differences

Disparities arising from the clinical Disparities arising from the clinical encounterencounter

Potential Sources of Racial and Ethnic Potential Sources of Racial and Ethnic Healthcare Disparities – Healthcare Disparities – Healthcare Systems-level FactorsHealthcare Systems-level Factors

Cultural and linguistic barriers – many non-Cultural and linguistic barriers – many non-English speaking patients report having English speaking patients report having difficulty accessing appropriate translation difficulty accessing appropriate translation servicesservices

Lack of stable relationships with primary Lack of stable relationships with primary care providers – minority patients, even when care providers – minority patients, even when insured at the same level as whites, are more insured at the same level as whites, are more likely to receive care in emergency rooms and likely to receive care in emergency rooms and have less access to private physicianshave less access to private physicians

Financial incentives to limit services – may Financial incentives to limit services – may disproportionately and negatively affect disproportionately and negatively affect minoritiesminorities

“ “Fragmentation” of healthcare financing Fragmentation” of healthcare financing and deliveryand delivery

Potential Sources of Racial and Ethnic Potential Sources of Racial and Ethnic Healthcare Disparities – Patient-level Healthcare Disparities – Patient-level FactorsFactors

Minority patients may be more likely to refuse Minority patients may be more likely to refuse recommended services, adhere poorly to recommended services, adhere poorly to treatment, and delay seeking caretreatment, and delay seeking care

These may develop as a result of poor cultural These may develop as a result of poor cultural match between patients and providers, match between patients and providers, misunderstanding of provider instructions, poor misunderstanding of provider instructions, poor prior interactions with health care systems, prior interactions with health care systems, lack of knowledge of how to best use serviceslack of knowledge of how to best use services

Patient level factors unlikely to be major Patient level factors unlikely to be major sources of healthcare disparitiessources of healthcare disparities

Potential Sources of Racial and Ethnic Potential Sources of Racial and Ethnic Healthcare Disparities - Healthcare Disparities - Disparities arising from the clinical Disparities arising from the clinical encounterencounter

The Core Paradox:The Core Paradox:

How could well-meaning and highly How could well-meaning and highly educated health professionals, working educated health professionals, working in their usual circumstances with diverse in their usual circumstances with diverse populations of patients, create a pattern populations of patients, create a pattern of care that appears to be of care that appears to be discriminatory?discriminatory?

Disparities in the Clinical Encounter: The Disparities in the Clinical Encounter: The Core ParadoxCore Paradox

Possibilities examined: bias (prejudice), Possibilities examined: bias (prejudice), uncertainty, stereotyping uncertainty, stereotyping

Bias – no evidence suggests that Bias – no evidence suggests that providers are more likely than the general providers are more likely than the general public to express biases, but some public to express biases, but some evidence suggests that unconscious evidence suggests that unconscious biases may existbiases may exist

Uncertainty – a plausible hypothesis, Uncertainty – a plausible hypothesis, particularly when providers treat patients particularly when providers treat patients that are dissimilar in cultural or linguistic that are dissimilar in cultural or linguistic backgroundbackground

Stereotyping – evidence suggests that Stereotyping – evidence suggests that providers, like everyone else, use these providers, like everyone else, use these ‘cognitive shortcuts’‘cognitive shortcuts’

Disparities in the Clinical Encounter Disparities in the Clinical Encounter Stereotyping: A DefinitionStereotyping: A Definition

Stereotyping can be defined as the process Stereotyping can be defined as the process by which people use social categories by which people use social categories (e.g. race, sex) in acquiring, processing, (e.g. race, sex) in acquiring, processing, and recalling information about others.and recalling information about others.

Stereotyping beliefs may serve important Stereotyping beliefs may serve important functions - organizing and simplifying complex functions - organizing and simplifying complex situations and giving people greater confidence situations and giving people greater confidence in their ability to understand, predict, and in their ability to understand, predict, and potentially control situations and people.potentially control situations and people.

Disparities in the Clinical Encounter Disparities in the Clinical Encounter Stereotyping: RisksStereotyping: Risks

Can exert powerful effects on thinking and Can exert powerful effects on thinking and actions at an implicit, unconscious level, actions at an implicit, unconscious level, even among well-meaning, well-educated even among well-meaning, well-educated persons who are not overtly biased.persons who are not overtly biased.

Can influence how information is Can influence how information is processed and recalled.processed and recalled.

Can exert “self-fulfilling” effects, as Can exert “self-fulfilling” effects, as patients’ behavior may be affected by patients’ behavior may be affected by providers’ overt or subtle attitudes and providers’ overt or subtle attitudes and behaviors.behaviors.

Disparities in the Clinical Encounter Disparities in the Clinical Encounter Stereotyping: When Is It in Action?Stereotyping: When Is It in Action?

Situations characterized by time Situations characterized by time pressure, resource constraints, and pressure, resource constraints, and high cognitive demand promote high cognitive demand promote stereotyping due to the need for stereotyping due to the need for cognitive ‘shortcuts’ and lack of full cognitive ‘shortcuts’ and lack of full information.information.

What is the Evidence that Physician What is the Evidence that Physician Biases and Stereotypes May Influence the Biases and Stereotypes May Influence the Clinical Encounter?Clinical Encounter?

van Ryn and Burke (2000) - study van Ryn and Burke (2000) - study conducted in actual clinical settings conducted in actual clinical settings found that doctors are more likely to found that doctors are more likely to ascribe negative racial stereotypes to ascribe negative racial stereotypes to their minority patients. These their minority patients. These stereotypes were ascribed to patients stereotypes were ascribed to patients even when differences in minority and even when differences in minority and non-minority patients’ education, income, non-minority patients’ education, income, and personality characteristics were and personality characteristics were considered.considered.

Finucane and Carrese (1990) - Physicians Finucane and Carrese (1990) - Physicians more likely to make negative comments more likely to make negative comments when discussing minority patients’ cases.when discussing minority patients’ cases.

What is the Evidence that Physician What is the Evidence that Physician Biases and Stereotypes may Influence the Biases and Stereotypes may Influence the Clinical Encounter (cont’d)?Clinical Encounter (cont’d)?

Rathore et al. (2000) – found that medical Rathore et al. (2000) – found that medical students were more likely to evaluate a students were more likely to evaluate a white male “patient” with symptoms of white male “patient” with symptoms of cardiac disease as having “definite” or cardiac disease as having “definite” or “probable” angina, relative to a black “probable” angina, relative to a black female “patient” with objectively similar female “patient” with objectively similar symptoms.symptoms.

Abreu (1999) – found that mental health Abreu (1999) – found that mental health professionals and trainees were more professionals and trainees were more likely to evaluate a hypothetical patient likely to evaluate a hypothetical patient more negatively after being “primed” with more negatively after being “primed” with words associated with African American words associated with African American stereotypes.stereotypes.

SUMMARY OF FINDINGSSUMMARY OF FINDINGS

Racial and ethnic disparities in health care Racial and ethnic disparities in health care exist and, because they are associated with exist and, because they are associated with worse outcomes in many cases, are worse outcomes in many cases, are unacceptable.unacceptable.

Racial and ethnic disparities in health care Racial and ethnic disparities in health care occur in the context of broader historic and occur in the context of broader historic and contemporary social and economic inequality, contemporary social and economic inequality, and evidence of and evidence of persistentpersistent racial and ethnic racial and ethnic discrimination in many sectors of American life.discrimination in many sectors of American life.

Many sources – including health systems, Many sources – including health systems, health care providers, patients, and utilization health care providers, patients, and utilization managersmanagers – contribute to racial and ethnic – contribute to racial and ethnic disparities in health care.disparities in health care.

 

SUMMARY OF FINDINGS (Continued)SUMMARY OF FINDINGS (Continued)

Bias, stereotyping, prejudice, and clinical Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare uncertainty on the part of healthcare providers may contribute to racial and providers may contribute to racial and ethnic disparities in healthcare. ethnic disparities in healthcare.

Racial and ethnic minority patients are Racial and ethnic minority patients are more likely than white patients to refuse more likely than white patients to refuse treatment, but differences in refusal rates treatment, but differences in refusal rates are generally small, and minority patient are generally small, and minority patient refusal does not fully explain healthcare refusal does not fully explain healthcare disparities.disparities.

SUMMARY OF SUMMARY OF RECOMMENDATIONSRECOMMENDATIONS

GENERAL RECOMMENDATIONGENERAL RECOMMENDATION

Increase awareness of racial and ethnic Increase awareness of racial and ethnic disparities in health care among the general disparities in health care among the general public and key stakeholders, and increase health public and key stakeholders, and increase health care providers’ awareness of disparities.care providers’ awareness of disparities.

  

LEGAL, REGULATORY, AND POLICY LEGAL, REGULATORY, AND POLICY RECOMMENDATIONSRECOMMENDATIONS

Avoid fragmentation of health plans along Avoid fragmentation of health plans along socioeconomic lines, and take measures to socioeconomic lines, and take measures to strengthen the stability of patient-provider strengthen the stability of patient-provider relationships in publicly funded health relationships in publicly funded health plans;plans;

Increase the proportion of Increase the proportion of underrepresented U.S. racial and ethnic underrepresented U.S. racial and ethnic minorities among health professionals;minorities among health professionals;

Apply the same managed care protections Apply the same managed care protections to publicly funded HMO enrollees that to publicly funded HMO enrollees that apply to private HMO enrollees;apply to private HMO enrollees;

Provide greater resources to the U.S. DHHS Provide greater resources to the U.S. DHHS Office of Civil Rights to enforce civil rights Office of Civil Rights to enforce civil rights laws.laws.

HEALTH SYSTEMS INTERVENTIONSHEALTH SYSTEMS INTERVENTIONS

Promote the consistency and equity of care through Promote the consistency and equity of care through the use of evidence-based guidelines;the use of evidence-based guidelines;

Structure payment systems to ensure an adequate Structure payment systems to ensure an adequate supply of services to minority patients, and limit supply of services to minority patients, and limit provider incentives that may promote disparities;provider incentives that may promote disparities;

Enhance patient-provider communication and trust by Enhance patient-provider communication and trust by providing financial incentives for practices that providing financial incentives for practices that reduce barriers and encourage evidence-based reduce barriers and encourage evidence-based practice;practice;

Promote the use of interpretation services where Promote the use of interpretation services where community need exists. The use of community health community need exists. The use of community health workers and multidisciplinary treatment and workers and multidisciplinary treatment and preventive care teams should also be supported.preventive care teams should also be supported.

EDUCATIONEDUCATION

Patient education programs should be Patient education programs should be implemented to increase patients’ implemented to increase patients’ knowledge of how to best access care and knowledge of how to best access care and participate in treatment decisions.participate in treatment decisions.

Integrate cross-cultural education into the Integrate cross-cultural education into the training of all current and future health training of all current and future health professionals.professionals.

DATA COLLECTION AND MONITORINGDATA COLLECTION AND MONITORING

Collect and report data on health care Collect and report data on health care

access and utilization by patients’ race, access and utilization by patients’ race, ethnicity, socioeconomic status, and where ethnicity, socioeconomic status, and where possible, primary language;possible, primary language;

Include measures of racial and ethnic Include measures of racial and ethnic disparities in performance measurement;disparities in performance measurement;

Monitor progress toward the elimination of Monitor progress toward the elimination of health care disparities;health care disparities;

Report racial and ethnic data by OMB Report racial and ethnic data by OMB categories, but use subpopulation groups categories, but use subpopulation groups where possible.where possible.

NEEDED RESEARCH NEEDED RESEARCH

Conduct further research to identify Conduct further research to identify sources of racial and ethnic disparities sources of racial and ethnic disparities and assess promising intervention and assess promising intervention strategies, and; strategies, and;

Conduct research on ethical issues and Conduct research on ethical issues and other barriers to eliminating disparities.other barriers to eliminating disparities.