Title: Unequal Treatment: Understanding and Eliminating Racial and Ethnic Disparities in Healthcare
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4- STUDY CHARGE
-
- Assess the extent of racial and ethnic
differences in healthcare that are not otherwise
attributable to known factors such as access to
care (e.g., ability to pay or insurance
coverage) - Evaluate potential sources of racial and ethnic
disparities in healthcare, including the role of
bias, discrimination, and stereotyping at the
individual (provider and patient), institutional,
and health system levels and, - Provide recommendations regarding interventions
to eliminate healthcare disparities.
5CAVEATS
- Access (e.g., insurance status, ability to pay
for healthcare) is the most important predictor
of the quality of healthcare across racial and
ethnic groups - It is difficult even artificial to separate
access-related factors from social categories
such as race and ethnicity - The bulk of research on healthcare disparities
has focused on black-white differences more
research is needed to understand disparities
among other racial and ethnic minority groups
6Differences, Disparities, and Discrimination
Populations with Equal Access to Health Care
Clinical Appropriateness and Need Patient
Preferences
Non-Minority
The Operation of Healthcare Systems and the
Legal and Regulatory Climate
Difference
Quality of Health Care
Minority
Disparity
Discrimination Biases and Prejudice,
Stereotyping, and Uncertainty
Populations with Equal Access to Health Care
7Evidence of Racial and Ethnic Disparities in
Healthcare
- Disparities consistently found across a wide
range of disease areas and clinical services - Disparities are found even when clinical factors,
such as stage of disease presentation,
co-morbidities, age, and severity of disease are
taken into account - Disparities are found across a range of clinical
settings, including public and private hospitals,
teaching and non-teaching hospitals, etc. - Disparities in care are associated with higher
mortality among minorities (e.g., Bach et al.,
1999 Peterson et al., 1997 Bennett et al., 1995)
8Among Medicare Beneficiaries Enrolled in Managed
Care Plans, African Americans Receive Poorer
Quality of Care (Schneider et al., JAMA, March
13, 2002)
9Black and White Differences in Specialty
Procedure Utilization Among Medicare
Beneficiaries Age 65 and Older, 1993
10What are potential sources of disparities in care?
- Health systems-level factors financing,
structure of care cultural and linguistic
barriers - Patient-level factors including patient
preferences, refusal of treatment, poor
adherence, biological differences - Disparities arising from the clinical encounter
11Potential Sources of Racial and Ethnic Healthcare
Disparities Healthcare Systems-level Factors
- Cultural and linguistic barriers many
non-English speaking patients report having
difficulty accessing appropriate translation
services - Lack of stable relationships with primary care
providers minority patients, even when insured
at the same level as whites, are more likely to
receive care in emergency rooms and have less
access to private physicians - Financial incentives to limit services may
disproportionately and negatively affect
minorities - Fragmentation of healthcare financing and
delivery
12Potential Sources of Racial and Ethnic Healthcare
Disparities Patient-level Factors
- Minority patients may be more likely to refuse
recommended services, adhere poorly to treatment,
and delay seeking care - These may develop as a result of poor cultural
match between patients and providers,
misunderstanding of provider instructions, poor
prior interactions with health care systems, lack
of knowledge of how to best use services - Patient level factors unlikely to be major
sources of healthcare disparities
13Potential Sources of Racial and Ethnic Healthcare
Disparities - Disparities arising from the
clinical encounter
- The Core Paradox
- How could well-meaning and highly educated health
professionals, working in their usual
circumstances with diverse populations of
patients, create a pattern of care that appears
to be discriminatory?
14Disparities in the Clinical Encounter The Core
Paradox
- Possibilities examined bias (prejudice),
uncertainty, stereotyping - Bias no evidence suggests that providers are
more likely than the general public to express
biases, but some evidence suggests that
unconscious biases may exist - Uncertainty a plausible hypothesis,
particularly when providers treat patients that
are dissimilar in cultural or linguistic
background - Stereotyping evidence suggests that providers,
like everyone else, use these cognitive
shortcuts
15Disparities in the Clinical Encounter
Stereotyping A Definition
- Stereotyping can be defined as the process by
which people use social categories (e.g. race,
sex) in acquiring, processing, and recalling
information about others. - Stereotyping beliefs may serve important
functions - organizing and simplifying complex
situations and giving people greater confidence
in their ability to understand, predict, and
potentially control situations and people.
16Disparities in the Clinical Encounter
Stereotyping Risks
- Can exert powerful effects on thinking and
actions at an implicit, unconscious level, even
among well-meaning, well-educated persons who are
not overtly biased. - Can influence how information is processed and
recalled. - Can exert self-fulfilling effects, as patients
behavior may be affected by providers overt or
subtle attitudes and behaviors.
17Disparities in the Clinical Encounter
Stereotyping When Is It in Action?
- Situations characterized by time pressure,
resource constraints, and high cognitive demand
promote stereotyping due to the need for
cognitive shortcuts and lack of full
information.
18What is the Evidence that Physician Biases and
Stereotypes May Influence the Clinical Encounter?
- van Ryn and Burke (2000) - study conducted in
actual clinical settings found that doctors are
more likely to ascribe negative racial
stereotypes to their minority patients. These
stereotypes were ascribed to patients even when
differences in minority and non-minority
patients education, income, and personality
characteristics were considered. - Finucane and Carrese (1990) - Physicians more
likely to make negative comments when discussing
minority patients cases.
19What is the Evidence that Physician Biases and
Stereotypes may Influence the Clinical Encounter
(contd)?
- Rathore et al. (2000) found that medical
students were more likely to evaluate a white
male patient with symptoms of cardiac disease
as having definite or probable angina,
relative to a black female patient with
objectively similar symptoms. - Abreu (1999) found that mental health
professionals and trainees were more likely to
evaluate a hypothetical patient more negatively
after being primed with words associated with
African American stereotypes.
20- SUMMARY OF FINDINGS
-
- Racial and ethnic disparities in health care
exist and, because they are associated with worse
outcomes in many cases, are unacceptable. - Racial and ethnic disparities in health care
occur in the context of broader historic and
contemporary social and economic inequality, and
evidence of persistent racial and ethnic
discrimination in many sectors of American life. - Many sources including health systems, health
care providers, patients, and utilization
managers contribute to racial and ethnic
disparities in health care. -
21- SUMMARY OF FINDINGS (Continued)
-
- Bias, stereotyping, prejudice, and clinical
uncertainty on the part of healthcare providers
may contribute to racial and ethnic disparities
in healthcare. - Racial and ethnic minority patients are more
likely than white patients to refuse treatment,
but differences in refusal rates are generally
small, and minority patient refusal does not
fully explain healthcare disparities.
22- SUMMARY OF RECOMMENDATIONS
- GENERAL RECOMMENDATION
- Increase awareness of racial and ethnic
disparities in health care among the general
public and key stakeholders, and increase health
care providers awareness of disparities. -
23- LEGAL, REGULATORY, AND POLICY RECOMMENDATIONS
- Avoid fragmentation of health plans along
socioeconomic lines, and take measures to
strengthen the stability of patient-provider
relationships in publicly funded health plans - Increase the proportion of underrepresented U.S.
racial and ethnic minorities among health
professionals - Apply the same managed care protections to
publicly funded HMO enrollees that apply to
private HMO enrollees - Provide greater resources to the U.S. DHHS Office
of Civil Rights to enforce civil rights laws.
24- HEALTH SYSTEMS INTERVENTIONS
- Promote the consistency and equity of care
through the use of evidence-based guidelines - Structure payment systems to ensure an adequate
supply of services to minority patients, and
limit provider incentives that may promote
disparities - Enhance patient-provider communication and trust
by providing financial incentives for practices
that reduce barriers and encourage evidence-based
practice - Promote the use of interpretation services where
community need exists. The use of community
health workers and multidisciplinary treatment
and preventive care teams should also be
supported.
25- EDUCATION
- Patient education programs should be implemented
to increase patients knowledge of how to best
access care and participate in treatment
decisions. - Integrate cross-cultural education into the
training of all current and future health
professionals.
26- DATA COLLECTION AND MONITORING
-
- Collect and report data on health care access and
utilization by patients race, ethnicity,
socioeconomic status, and where possible, primary
language - Include measures of racial and ethnic disparities
in performance measurement - Monitor progress toward the elimination of health
care disparities - Report racial and ethnic data by OMB categories,
but use subpopulation groups where possible.
27- NEEDED RESEARCH
- Conduct further research to identify sources of
racial and ethnic disparities and assess
promising intervention strategies, and - Conduct research on ethical issues and other
barriers to eliminating disparities.