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Health Disparities 101: Where are we, and what can you do

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Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Summary. ... Richard Wilkinson and Michael Marmot, eds. ... – PowerPoint PPT presentation

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Title: Health Disparities 101: Where are we, and what can you do


1
Health Disparities 101 Where are we, and what
can you do?
  • Cara V. James, Ph.D.
  • Senior Policy Analyst
  • March 28, 2009

2
What is a Health Care Disparity?
SOURCE Figure 1. Differences, Disparities, and
Discrimination Populations with Equal Access to
Healthcare. Unequal Treatment Confronting Racial
and Ethnic Disparities in Healthcare, Summary.
Brian Smedley, Adrianne Stith, and Alan Nelson,
Eds. Washington, DC. Institute of Medicine,
2002.
3
Perceptions of Disparities in Health Care
When going to a doctor or health clinic for
health care services, do you think most African
Americans receive the same quality of health care
as whites, higher quality of care or lower
quality of health care as most whites?
Same
Higher
Lower
Dont Know/Refused
Whites
Blacks
Hispanics
When going to a doctor or health clinic for
health care services, do you think most Latinos
receive the same quality of health care as
whites, higher quality of care or lower quality
of health care as most whites?
Same
Higher
Lower
Dont Know/Refused
Whites
Blacks
Hispanics
SOURCE Kaiser Family Foundation, March/April
2006 Kaiser Health Poll Report Survey, April 2006
(Conducted April 2006)
4
Physicians Awareness of Racial/Ethnic Health
Disparities, 2005
  • 24 of physicians believe minority patients
    generally receive the same or better quality care
    than white patients and 55 believed they
    received lower quality
  • 62 reported having witnessed a patient receiving
    poor quality health care because of the patients
    race

SOURCE Institute for Ethics. (April 2005).
Physicians are becoming engaged in addressing
disparities. Preliminary Survey Brief.
http//www.ama-assn.org/ama/pub/category/14969.htm
l. Accessed March 12, 2008.
5
Distribution of U.S. Population by
Race/Ethnicity, 2006
Total U.S. Population 299.4 million
DATA March Current population Survey,
2006. SOURCE KFF and Urban Institute estimates
6
Percent Distribution of All Asian Americans,
Native Hawaiians and Pacific Islanders in the
U.S., 2004-2006
Total 12.9 million
NOTE 3rd Plus Generation includes Individuals
who reported their and their parents country of
birth as the US. DATA March Current population
Survey, 2004, 2005 and 2006, three-year pooled
data. SOURCE KFF and Urban Institute estimates
7
Percent Distribution of Hispanic Americans, 2004
Total Population 40.5 million
DATA U.S. Census Bureau, 2004 American Community
Survey, Selected Population Profiles and Detailed
Tables, B03001. SOURCE The American Community
Hispanics 2004. http//www.census.gov/prod/www/ab
s/popula.htmlpop
8
Brief History of Disparities
  • Differences in US go back to slavery
  • Most research has been on Black-White differences
  • Heckler Report
  • Surgeon General David Satcher and Health People
    2010
  • Minority Health and Health Disparities Research
    and Education Act of 2000
  • Institute of Medicines Unequal Treatment
  • AHRQs National Healthcare Disparities Report

9
Death Rate due to Heart Disease by
Race/Ethnicity, 2005
Deaths per 100,000 population
NOTES Rates are age-adjusted. DATA Centers
for Disease Control and Prevention, National
Center for Health Statistics, National Vital
Statistics System. SOURCE Health US, 2007,
Table 36.
10
Cancer Deaths Rates by Race/Ethnicity, 2004
Deaths per 100,000 population
NOTE Breast cancer rate is per 100,000 female
population other rates are for both genders.
DATA Centers for Disease Control and
Prevention, National Center for Vital
Statistics. SOURCE National Healthcare
Disparities Report, 2007, available at
http//www.ahrq.gov/qual/nhdr07/index.html.
11
New AIDS Case Rate Age 13 and Over by
Race/Ethnicity, 2005
Rate per 100,000 population
NOTE Data are for adult population only and
reflect admissions for uncontrolled diabetes
without complication. DATA Agency for
Healthcare Research and Quality, Healthcare Cost
and Utilization Project. SOURCE National
Healthcare Disparities Report, 2007, available
at http//www.ahrq.gov/qual/nhdr07/index.html.
12
No Usual Source of Health Care Adults 18-64, by
Race/Ethnicity, 2005-2006
NOTE The samples size for Native
Hawaiian/Pacific Islander was not large enough
for reliable estimates. DATA National Center
for Health Statistics, National Health Interview
Survey, 2005-2006 SOURCE Health, United States,
2007, Table 77
13
No Dental Visit in Past Year, by Race/Ethnicity,
2006
SOURCE Table 96. Dental visits in the past
year, by selected characteristics United
States, 1997, 2005, and 2006. Health US, 2008.
National Center for Health Statistics, CDC.
14
Pneumonia Patients Who Received Recommended
Hospital Care, 2005
SOURCE U.S. Department of Health and Human
Services Agency for Healthcare Research and
Quality. National Healthcare Disparities Report,
2007. Rockville, MD. AHRQ Publication No. 08-0041
15
Changes in Quality Measure Disparities Over Time,
2000-2001 to 2004-2005
SOURCE Agency for Healthcare Research and
Quality. National Healthcare Disparities Report,
2007.
16
Factors that Lead to Health Disparities
  • Provider-level factors
  • Patient-level factors
  • System-level factors
  • Factors not directly related to the health care
    system (i.e. social determinants)

17
Social Determinants of Health
  • Addiction
  • Food
  • Transportation
  • Caras Additions
  • Health Insurance
  • Literacy and Language
  • The Social Gradient
  • Stress
  • Early life
  • Social Exclusion
  • Work
  • Unemployment
  • Social Support

Richard Wilkinson and Michael Marmot, eds. Social
Determinants of Health The Solid Facts, 2nd
Edition. Denmark World Health Organization,
2003. Also available online at
http//www.euro.who.int/eprise/main/who/informatio
nsources/publications/catalogue/20020808_2.
18
Limited English Proficiency (LEP)
  • In 2005, nearly 52 million people in the U.S.
    spoke a language other than English at home
  • More than 12 million people speak English not
    well or not at all, and over 23 million speak
    English less than very well (LEP)
  • LEP patients have decreased access to services
    and sometimes receive lower quality care (Sentall
    et al., 2007)

SOURCE Alyssa Sampson. Language Services
Resource Guide For health care providers.
National health Law Program, October 2006.
19
Share of Population that is a Member of a
Racial/Ethnic Minority by State, 2005-2006
Less than 14 (11 states) 14 to 21 (13
states) 22 to 36 (14 states) More than 37 (13
states)
DATA March 2005 and March 2006 Current
Population Survey SOURCE Urban Institute and
Kaiser Commission on Medicaid and the Uninsured
estimates.
20
Percent Low-Birthweight by Geography and
Race/Ethnicity, 2002-2004
Top performing geographic area Bottom
performing geographic area
SOURCE Health US 2006. Table 8. Early prenatal
care by race and Hispanic origin of mother,
geographic division, and state United States,
average annual 1996-1998, 1999-2001, and
2002-2004.
21
Health System-Level Variables that Impact Health
Disparities
  • Language barriers
  • Availability of services
  • Access to services
  • Clinical bureaucracy
  • Referral patterns and access to specialty care
  • Fragmentation of the healthcare system
  • Managed care
  • Supply-side cost containment and demand for
    clinical services
  • Legal and regulatory policies

SOURCE Smedley BD, Stith AY, and Nelson, Eds.
(2003). Unequal Treatment Confronting Racial
and Ethnic Disparities in Health Care.
Washington, DC Institute of Medicine of the
National Academies
22
Financial Incentives
  • Capitation and bundled payments for services
  • Bonus payments for achieving management targets
  • Losing contracts with insurers
  • Pay-for-performance (P4P)
  • Has potential to negatively impact racial and
    ethnic disparities

23
Contribution of Provider Factors to Racial/Ethnic
Health Disparities
  • Potential mechanisms for disparities (IOM, 2003)
  • Greater clinical uncertainty
  • Beliefs (or stereotypes) held by the provider
    regarding the health and behavior of minorities
  • Bias or prejudice
  • Pathways through which providers can affect
    disparities include
  • Treatment (quality)
  • Referrals
  • Communication

24
Provider Bias
  • Education Breast cancer patients with less
    education were less likely to say physicians
    discussed surgical options (Keating et al, 2003)
  • Gender Women with heart problems less likely to
    get aggressive treatment (Schulman et al, 1999)
  • Race Physicians rated Black patients as less
    intelligent, less educated, more likely to abuse
    drugs and alcohol, more likely to fail to comply
    with medical advices, more likely to lack social
    support, and less likely to participate in
    cardiac rehabilitation than white patients (van
    Ryn and Burke, 2000)

25
Public Health Workforce to U.S. Population Ratios
Confronting the Public Health Workforce Crisis
ASPH Statement on the Public Health Workforce.
Assoc. of Schools of Public Health. February
2008. http//www.asph.org/document.cfm?page1039
Assessed March 13, 2008.
26
Distribution of U.S. Population and Physicians by
Race/Ethnicity, 2006
Total 299.4 million
Total 921,904
DATA March Current Population Survey, 2006 and
Physician Characteristics and Distribution in the
US, 2008 Edition. American Medical Association.
27
Diversity Among U.S. Health Care Professions,
Selected Years 2000-2006
SOURCE Grumbach K and Mendoza R. Disparities in
human resources addressing the lack of diversity
in the health professions. Health Affairs 2008
27(2) 413-422.
28
Potential Policy Levers for Eliminating Health
Disparities
  • Coverage
  • Piecemeal efforts vs. comprehensive efforts
  • Fragmentation of the health care system
  • Language access (who should pay?)
  • Reimbursement rates and other incentives
  • Provider training for cultural competence
  • Social policies (education, job training,
    housing)
  • Health information technology

29
Federal Efforts to Address Health Disparities
  • Federal Office of Minority Health
  • Efforts within HHS
  • Department of Health and Human Services (DHHS)
    Interagency Working Group on Health Disparities
  • Health Disparities Collaboratives
  • Healthy People 2020
  • Data Collection
  • Legislation
  • Reimbursement rates to providers
  • Language access laws
  • Title VI of the Civil Rights Act of 1964
  • Medical malpractice

30
Examples of System-Level Efforts to Eliminate
Disparities
  • Insurance Companies
  • National Health Plan Collaborative (NHPC)
  • Pay-for-Performance (P4P)
  • Disease registries
  • Massachusetts General Hospital Disparities
    Solutions Center
  • Johns Hopkins Center for Health Disparities

31
Take Home Messages
  • Disparities exist
  • Regardless of how they fair in the aggregate, all
    racial groups have problems.
  • Racial groups are not monolithic.
  • Many factors aside from race impact health and
    health care.
  • A myriad of efforts are underway to address
    disparities.
  • Overall, we still have a long way to go to
    eliminate disparities.
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