Health Care in America — Still Too Separate, Not Yet Equal
http://www.100md.com
《新英格兰医药杂志》
In the 50 years since the civil-rights movement began we have seen growth in the racial and ethnic diversity of the American people, as well as encouraging evidence that members of racial and ethnic minorities, including black Americans, have increasingly moved into positions of economic opportunity and prestige. For example, blacks, who make up approximately 12 percent of the population, accounted for only 4.3 percent of college graduates in 19591 — a proportion that nearly doubled, to 7.9 percent, by 2002.2 We have also seen growth in the proportion of blacks who work as professionals, including as physicians. In 1983, blacks made up just 3 percent of the physician workforce3; today, they account for 5 percent.2 More than 7 percent of the nation's medical students are now black,4 as compared with just 2.2 percent in 1964.5
Despite these markers of social progress and integration, much remains to be done. The United States is still a society in which racial and ethnic characteristics are strongly associated with socioeconomic class and opportunity. The article by Bach et al.6 in this issue of the Journal reminds us that, in health care, integration is not complete and separate is not equal. Linking survey data from more than 4300 primary care doctors who participated in the Community Tracking Study with the visits of more than 43,000 Medicare patients allowed the authors to understand better where black patients and white patients received their primary care and whether the physicians who provided their care differed with regard to their training and their ability to provide access to clinical services for their patients. The findings confirmed some of what we believe about racial and ethnic disparities but also offered some surprises.
Care for black patients turned out to be concentrated within a relatively small group of physicians; 22 percent of the doctors provided 80 percent of the visits with black patients. Although black patients were more likely than their white counterparts to receive care from black clinicians, the large majority of their visits were with nonblack clinicians. Irrespective of their race, the clinicians caring for black patients were less likely to be board certified than those caring for white patients and less likely to say that they could always or nearly always provide access to high-quality subspecialists, high-quality diagnostic imaging, high-quality ancillary services, and nonemergency admission to the hospital. Surprisingly, though, these differences appeared to result more from geography than from the patients' choice of physician: the ability of a doctor to provide access to care closely reflected the ability of other doctors practicing in the same geographic area. Thus, the disparities between the health care received by black patients and that received by white patients seem to reflect the place in which patients seek care, rather than the specific doctor they choose within that place.
Much of the literature on mediators of racial disparities in the provision of health care has focused on characteristics of the patients, such as their ability to afford care,7 their knowledge and beliefs,8 and their preferences,9 as well as on aspects of the doctor–patient relationship that involve patients' education,10 trust,11 and the physician's sensitivity to a patient's culture.12 These factors may be important, and, indeed, there is now a broad effort to improve the cultural competency of physicians who care for patients whose ethnic backgrounds differ from theirs. The findings of Bach et al., however, suggest that there are structural features of the delivery system that also contribute to racial disparities in the quality of care.
These findings are both reassuring and disturbing. Many have worried that racial differences in the use of health care services stem from conscious or unconscious bias on the part of physicians. The findings suggest an alternate pathway and point away from interpersonal discrimination. They still point, however, to long-standing societal discrimination. The residue of segregation that probably accounts for differences in the locations where patients seek care plays a role in all kinds of opportunity, including the opportunity to obtain health care. Moreover, the policy remedies for improving the quality of care in this regard may be difficult to identify. Some remedies may involve quite broad changes in economic and social policy and would go far beyond individual physicians, even those whose practices largely comprise minority-group patients. Beneath the gross summary statistics on access to care provided by Bach et al. is a complex delivery system, and before any solutions can emerge, the medical community needs to understand what practice is actually like for the relatively small number of physicians in urban settings where a disproportionate number of minority-group patients receive care.
We might also consider that efforts to improve the quality of care in general might reduce racial disparities in the quality of care. This is so because racial and ethnic disparities in care are, in some ways, just another manifestation of the broad problems in quality of care that exist throughout our health care system. There have been continuing efforts by the accrediting organizations, such as the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations, by large payers such as the Centers for Medicare and Medicaid Services, and by the National Quality Forum to identify and develop a set of indicators that could be used to measure the quality of care for a broader range of clinical conditions and to guide the improvement of care provided by health plans, hospitals, and other care settings.
Ongoing measurements of quality in health plans and the public dissemination of the data collected have prompted successful efforts to improve the quality of care.13 Historically, health plans have been reluctant to collect data on race and ethnic background, in part because of concern that consumers and their advocates might accuse them of racial profiling or of intending to use the data in decisions about underwriting and coverage. Now, health plans are showing much greater interest in efforts to collect such data as part of their goal of improving the quality of care — a goal that includes understanding and reducing racial disparities in quality.14 Patients who are minority-group members are more receptive to the need of providers to collect these data when they know the reason for them is to improve the quality of their own care.
However, certain programs recently developed by purchasers of care and health plans to improve the quality of care may have untoward consequences for racial disparities in the provision of care. For example, there is increasing interest in the concept of "paying for performance" — providing higher financial remuneration to the doctors and medical groups that achieve higher scores on quality indicators or who have made investments in infrastructure for their practice such as electronic medical records. Presumably, given constrained budgets, these incentives amount to lower payments to practices that are unable to achieve high scores or make the requisite investments.15 The danger for members of racial and ethnic minorities is that such payments will flow preferentially to practices that are already well endowed with information technology and therefore more readily capable of higher performance than the poor practices that serve members of racial minorities. The result will be that poorer practices will become even poorer and will still lack access to the services required to provide high-quality care. We need to consider the possible effect of such programs as we continue to address the disparities in the ability to provide access to care that have been identified by Bach et al.
Taking a broad view, the observation that the vast majority of black patients are cared for by physicians who practice in settings where it may be difficult to deliver high-quality care complements other information we have about the causes of racial and ethnic disparities in the use of health care services and in health outcomes. Surely, there are still unanswered questions relating to the differences in care, and it behooves us to address them. However, describing and explaining racial disparities in the use of health care services have proved much easier to accomplish than devising strategies to reduce the disparities. Researchers who work in this field and policymakers who attend to this area would serve us well by shifting their focus much more to the development of effective policies to reduce ethnic and racial disparities and improving the quality of care.
I am indebted to Joseph Betancourt, M.D., Risa Lavizzo-Mourey, M.D., and Nicole Luri, M.D., for comments on earlier versions of this editorial.
Source Information
From the Department of Health Policy and Management, Harvard School of Public Health; and the Section on Health Services and Policy Research, Division of General Medicine, Department of Medicine, Brigham and Women's Hospital — both in Boston.
References
Statistical abstract of the United States, 1966. Washington, D.C.: Bureau of the Census, 1966.
Statistical abstract of the United States, 2003. Washington, D.C.: Bureau of the Census, 2003.
Statistical abstract of the United States, 1980. Washington, D.C.: Bureau of the Census, 1980.
Minority students in medical education: facts and figures XII. Washington, D.C.: Association of American Medical Colleges, 2002. (Accessed July 15, 2004, at https://services.aamc.org/Publications/showfile.cfm?file=version12.pdf&CFID=236049&CFTOKEN=1de82ee-a3e60411-3e17-4ba4-8506-19a79c6b783d.)
Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000: racial and ethnic diversity in U.S. medical schools. N Engl J Med 1994;331:472-476.
Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575-584.
Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325-331.
Margolis ML, Christie JD, Silvestri GA, Kaiser L, Santiago S, Hansen-Flaschen J. Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey. Ann Intern Med 2003;139:558-563.
Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients' preferences on racial differences in access to renal transplantation. N Engl J Med 1999;341:1661-1669.
Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Med Care 2002;40:Suppl:I-27.
Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med 2000;9:1156-1163.
Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med 1999;130:829-834.
State of health care quality: 2002. Washington, D.C.: National Committee for Quality Assurance, 2002.
Winslow R. To close gaps in care more health plans ask about race. Wall Street Journal. June 1, 2004:B1.
Epstein AM, Lee TH, Hamel MB. Paying physicians for high-quality care. N Engl J Med 2004;350:1910-1912.
Related Letters:
Primary Care Physicians Who Treat Blacks and Whites
Aaron H. J., Fernandez A., Goldstein L., Wheeler M. B., Bach P. B., Schrag D., Pham H. H.(Arnold M. Epstein, M.D.)
Despite these markers of social progress and integration, much remains to be done. The United States is still a society in which racial and ethnic characteristics are strongly associated with socioeconomic class and opportunity. The article by Bach et al.6 in this issue of the Journal reminds us that, in health care, integration is not complete and separate is not equal. Linking survey data from more than 4300 primary care doctors who participated in the Community Tracking Study with the visits of more than 43,000 Medicare patients allowed the authors to understand better where black patients and white patients received their primary care and whether the physicians who provided their care differed with regard to their training and their ability to provide access to clinical services for their patients. The findings confirmed some of what we believe about racial and ethnic disparities but also offered some surprises.
Care for black patients turned out to be concentrated within a relatively small group of physicians; 22 percent of the doctors provided 80 percent of the visits with black patients. Although black patients were more likely than their white counterparts to receive care from black clinicians, the large majority of their visits were with nonblack clinicians. Irrespective of their race, the clinicians caring for black patients were less likely to be board certified than those caring for white patients and less likely to say that they could always or nearly always provide access to high-quality subspecialists, high-quality diagnostic imaging, high-quality ancillary services, and nonemergency admission to the hospital. Surprisingly, though, these differences appeared to result more from geography than from the patients' choice of physician: the ability of a doctor to provide access to care closely reflected the ability of other doctors practicing in the same geographic area. Thus, the disparities between the health care received by black patients and that received by white patients seem to reflect the place in which patients seek care, rather than the specific doctor they choose within that place.
Much of the literature on mediators of racial disparities in the provision of health care has focused on characteristics of the patients, such as their ability to afford care,7 their knowledge and beliefs,8 and their preferences,9 as well as on aspects of the doctor–patient relationship that involve patients' education,10 trust,11 and the physician's sensitivity to a patient's culture.12 These factors may be important, and, indeed, there is now a broad effort to improve the cultural competency of physicians who care for patients whose ethnic backgrounds differ from theirs. The findings of Bach et al., however, suggest that there are structural features of the delivery system that also contribute to racial disparities in the quality of care.
These findings are both reassuring and disturbing. Many have worried that racial differences in the use of health care services stem from conscious or unconscious bias on the part of physicians. The findings suggest an alternate pathway and point away from interpersonal discrimination. They still point, however, to long-standing societal discrimination. The residue of segregation that probably accounts for differences in the locations where patients seek care plays a role in all kinds of opportunity, including the opportunity to obtain health care. Moreover, the policy remedies for improving the quality of care in this regard may be difficult to identify. Some remedies may involve quite broad changes in economic and social policy and would go far beyond individual physicians, even those whose practices largely comprise minority-group patients. Beneath the gross summary statistics on access to care provided by Bach et al. is a complex delivery system, and before any solutions can emerge, the medical community needs to understand what practice is actually like for the relatively small number of physicians in urban settings where a disproportionate number of minority-group patients receive care.
We might also consider that efforts to improve the quality of care in general might reduce racial disparities in the quality of care. This is so because racial and ethnic disparities in care are, in some ways, just another manifestation of the broad problems in quality of care that exist throughout our health care system. There have been continuing efforts by the accrediting organizations, such as the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations, by large payers such as the Centers for Medicare and Medicaid Services, and by the National Quality Forum to identify and develop a set of indicators that could be used to measure the quality of care for a broader range of clinical conditions and to guide the improvement of care provided by health plans, hospitals, and other care settings.
Ongoing measurements of quality in health plans and the public dissemination of the data collected have prompted successful efforts to improve the quality of care.13 Historically, health plans have been reluctant to collect data on race and ethnic background, in part because of concern that consumers and their advocates might accuse them of racial profiling or of intending to use the data in decisions about underwriting and coverage. Now, health plans are showing much greater interest in efforts to collect such data as part of their goal of improving the quality of care — a goal that includes understanding and reducing racial disparities in quality.14 Patients who are minority-group members are more receptive to the need of providers to collect these data when they know the reason for them is to improve the quality of their own care.
However, certain programs recently developed by purchasers of care and health plans to improve the quality of care may have untoward consequences for racial disparities in the provision of care. For example, there is increasing interest in the concept of "paying for performance" — providing higher financial remuneration to the doctors and medical groups that achieve higher scores on quality indicators or who have made investments in infrastructure for their practice such as electronic medical records. Presumably, given constrained budgets, these incentives amount to lower payments to practices that are unable to achieve high scores or make the requisite investments.15 The danger for members of racial and ethnic minorities is that such payments will flow preferentially to practices that are already well endowed with information technology and therefore more readily capable of higher performance than the poor practices that serve members of racial minorities. The result will be that poorer practices will become even poorer and will still lack access to the services required to provide high-quality care. We need to consider the possible effect of such programs as we continue to address the disparities in the ability to provide access to care that have been identified by Bach et al.
Taking a broad view, the observation that the vast majority of black patients are cared for by physicians who practice in settings where it may be difficult to deliver high-quality care complements other information we have about the causes of racial and ethnic disparities in the use of health care services and in health outcomes. Surely, there are still unanswered questions relating to the differences in care, and it behooves us to address them. However, describing and explaining racial disparities in the use of health care services have proved much easier to accomplish than devising strategies to reduce the disparities. Researchers who work in this field and policymakers who attend to this area would serve us well by shifting their focus much more to the development of effective policies to reduce ethnic and racial disparities and improving the quality of care.
I am indebted to Joseph Betancourt, M.D., Risa Lavizzo-Mourey, M.D., and Nicole Luri, M.D., for comments on earlier versions of this editorial.
Source Information
From the Department of Health Policy and Management, Harvard School of Public Health; and the Section on Health Services and Policy Research, Division of General Medicine, Department of Medicine, Brigham and Women's Hospital — both in Boston.
References
Statistical abstract of the United States, 1966. Washington, D.C.: Bureau of the Census, 1966.
Statistical abstract of the United States, 2003. Washington, D.C.: Bureau of the Census, 2003.
Statistical abstract of the United States, 1980. Washington, D.C.: Bureau of the Census, 1980.
Minority students in medical education: facts and figures XII. Washington, D.C.: Association of American Medical Colleges, 2002. (Accessed July 15, 2004, at https://services.aamc.org/Publications/showfile.cfm?file=version12.pdf&CFID=236049&CFTOKEN=1de82ee-a3e60411-3e17-4ba4-8506-19a79c6b783d.)
Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000: racial and ethnic diversity in U.S. medical schools. N Engl J Med 1994;331:472-476.
Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575-584.
Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325-331.
Margolis ML, Christie JD, Silvestri GA, Kaiser L, Santiago S, Hansen-Flaschen J. Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey. Ann Intern Med 2003;139:558-563.
Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients' preferences on racial differences in access to renal transplantation. N Engl J Med 1999;341:1661-1669.
Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Med Care 2002;40:Suppl:I-27.
Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med 2000;9:1156-1163.
Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med 1999;130:829-834.
State of health care quality: 2002. Washington, D.C.: National Committee for Quality Assurance, 2002.
Winslow R. To close gaps in care more health plans ask about race. Wall Street Journal. June 1, 2004:B1.
Epstein AM, Lee TH, Hamel MB. Paying physicians for high-quality care. N Engl J Med 2004;350:1910-1912.
Related Letters:
Primary Care Physicians Who Treat Blacks and Whites
Aaron H. J., Fernandez A., Goldstein L., Wheeler M. B., Bach P. B., Schrag D., Pham H. H.(Arnold M. Epstein, M.D.)