Health Care Disparities:Health Care Disparities:Patient perspectives on Patient perspectives on navigating the health navigating the health

care systemcare systemElizabeth Bade, MDElizabeth Bade, MD

Jennifer Evertsen, MSJennifer Evertsen, MSSabrina Smiley, MPHSabrina Smiley, MPH

IntroductionIntroduction In Milwaukee significant differences exist In Milwaukee significant differences exist

in health markers between African in health markers between African Americans and CaucasiansAmericans and Caucasians– Oct. 2007 WMJ – infant mortality, STD rate, Oct. 2007 WMJ – infant mortality, STD rate,

increase in violent deaths, cigarette increase in violent deaths, cigarette smoking, access to health care, teen smoking, access to health care, teen pregnancy rate, all higher in Milwaukee pregnancy rate, all higher in Milwaukee among minoritiesamong minorities

Wisconsin’s 2010 goals: eliminate Wisconsin’s 2010 goals: eliminate disparitiesdisparities

GoalsGoals To determine perceptions of health and To determine perceptions of health and

what perceived barriers to health and what perceived barriers to health and healthcare exist in Milwaukee for a healthcare exist in Milwaukee for a population of minority – primarily African population of minority – primarily African American - people living in urban MilwaukeeAmerican - people living in urban Milwaukee– Are patients with a medical home Are patients with a medical home

satisfied/comfortable with their physician and satisfied/comfortable with their physician and carecare

– Have they experienced discrimination in the Have they experienced discrimination in the health care system in the pasthealth care system in the past

ProposalProposal To host a series of To host a series of

focus groups with focus groups with African American African American residents of the inner residents of the inner city of Milwaukeecity of Milwaukee– including a group with including a group with

case managers of case managers of community dwelling community dwelling mentally ill patients mentally ill patients who navigate the who navigate the health care system on health care system on behalf of their clientsbehalf of their clients

MethodsMethods Recruited patients from an inner city Recruited patients from an inner city

family practice clinic in Milwaukee family practice clinic in Milwaukee and from the surrounding communityand from the surrounding community

Used an outside moderator for the Used an outside moderator for the groups with a research assistant groups with a research assistant sitting in and taking notessitting in and taking notes

MethodsMethods Each group was recorded to be Each group was recorded to be

transcribed at a later timetranscribed at a later time– Participants were given pseudonyms to Participants were given pseudonyms to

use for the recordinguse for the recording Transcripts were then read by three Transcripts were then read by three

authorsauthors– Looked for themes independently then Looked for themes independently then

compared themes to come to a compared themes to come to a consensusconsensus

DemographicsDemographics

MaleFemale

0%

5%

10%

15%

20%

25%

18-25 26-35 36-45 46-55 56+ Age

Age

Total of 5 focus groups with a total of 25 participantsTotal of 5 focus groups with a total of 25 participants– 3 groups with Family Care Center patients3 groups with Family Care Center patients– 1 group of community dwelling mentally ill patients of FCC1 group of community dwelling mentally ill patients of FCC– 1 group of people from the neighborhood of the FCC1 group of people from the neighborhood of the FCC

One additional group of case managers for mentally ill One additional group of case managers for mentally ill patients (additional 5 participants) not included in patients (additional 5 participants) not included in demographicsdemographics

DemographicsDemographics

<$10K$10-25K$26-40$41-55K

96% African 96% African AmericanAmerican

52% with a chronic 52% with a chronic illnessillness

78% unemployed78% unemployed

Annual Income of Participants

QuestionsQuestions What do you feel most affects your health?What do you feel most affects your health? Have you or someone you know ever been Have you or someone you know ever been

treated unfairly by the healthcare system?treated unfairly by the healthcare system? What are the biggest barriers to health care What are the biggest barriers to health care

for you and members of your community?for you and members of your community? How well do you think your current doctor How well do you think your current doctor

responds to your needs?responds to your needs? Do you feel comfortable asking medical Do you feel comfortable asking medical

professional questions about your care?professional questions about your care? If you could change one thing about the If you could change one thing about the

healthcare system, what would it be?healthcare system, what would it be?

Results/ThemesResults/Themes1.1. Difficulty with insurance coverage, Difficulty with insurance coverage,

accessibility, stability, and choicesaccessibility, stability, and choices 2.2. Socioeconomic and racial factorsSocioeconomic and racial factors 3.3. Misunderstanding of the health care Misunderstanding of the health care

system and a lack of health literacysystem and a lack of health literacy 4.4. Lack of personal accountability for Lack of personal accountability for

health and health carehealth and health care

What most affects your What most affects your health…health…

Family HistoryFamily History InsuranceInsurance

Doctors or the systemDoctors or the system Personal habits (diet, Personal habits (diet,

exercise, etc)exercise, etc)

““I don’t know where to pinpoint it, I don’t know where to pinpoint it, either the doctor itself or my either the doctor itself or my insurance company, you know, cause insurance company, you know, cause if the doctor can’t cover it through if the doctor can’t cover it through my insurance then I never get it”my insurance then I never get it”

Have you (or your clients) ever Have you (or your clients) ever been treated unfairly…been treated unfairly…

Insurance Insurance changes/coveragechanges/coverage

Wait timesWait times

Case managers noted a Case managers noted a difference in availability difference in availability of appointments for of appointments for themselves vs. their themselves vs. their clientsclients

““Wait time, just the attitude of the Wait time, just the attitude of the medical staff. I think they always medical staff. I think they always think you’re abusing the ER when you think you’re abusing the ER when you show up with a Title 19 card, like…show up with a Title 19 card, like…why don’t you have a primary why don’t you have a primary doctor?”doctor?”

Do you feel comfortable asking Do you feel comfortable asking questions of medical questions of medical

providers…providers… FCC patients uniformly said ‘yes’FCC patients uniformly said ‘yes’ Women seemed to consistently say ‘yes’Women seemed to consistently say ‘yes’ People with less experience in the People with less experience in the

system seemed to be less comfortablesystem seemed to be less comfortable

““I be scared to ask them cause I figure I be scared to ask them cause I figure hey they know their job. And I be scared hey they know their job. And I be scared that they think I’m telling them how to that they think I’m telling them how to do their job.”do their job.”

What are the biggest What are the biggest barriers…barriers…

Insurance/moneyInsurance/money TransportationTransportation Safe, affordable housing, Safe, affordable housing,

social/economic struggles (identified by social/economic struggles (identified by case managers)case managers)

““Our community ain’t coming Our community ain’t coming together..We not being heard enough.”together..We not being heard enough.”

If you could change one If you could change one thing…thing…

““I think if you in the United States and I think if you in the United States and you a citizen, I don’t think you should you a citizen, I don’t think you should have to pay for healthcare.”have to pay for healthcare.”

DiscussionDiscussion Few participants named race as barrier, Few participants named race as barrier,

mostly insurance, economic issuesmostly insurance, economic issues– Dangerous ways around these issuesDangerous ways around these issues

““Quality” in a physician meant being Quality” in a physician meant being available and consistentavailable and consistent

Very few people acknowledged or Very few people acknowledged or discussed the ability to affect their own discussed the ability to affect their own health with lifestyle choices health with lifestyle choices

ConclusionsConclusions Simplifying insurance company's methods Simplifying insurance company's methods

would aid understanding and reduce would aid understanding and reduce frustrationsfrustrations

Including transportation, medication costs Including transportation, medication costs under covered services would allow greater under covered services would allow greater access to patientsaccess to patients

Addressing social issues first may help Addressing social issues first may help improve over all healthimprove over all health

Next step may need to be both political and Next step may need to be both political and driven by the healthcare systemdriven by the healthcare system

Future OpportunitiesFuture Opportunities Learning/listening sessions with Learning/listening sessions with

healthcare workers and patients to healthcare workers and patients to explain how to better communicate explain how to better communicate with insurance companies and with with insurance companies and with doctorsdoctors

Looking at the difference in perceived Looking at the difference in perceived health between people who have a health between people who have a medical home and those who don’tmedical home and those who don’t

Empowering patients to advocate for Empowering patients to advocate for their own healththeir own health

AcknowledgementsAcknowledgements Faculty mentor at Faculty mentor at

AUWMG – Dennis AUWMG – Dennis BaumgardnerBaumgardner

Patients and focus Patients and focus group participantsgroup participants

Faculty at the Faculty at the University of University of Wisconsin Primary Wisconsin Primary Care FellowshipCare Fellowship

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