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

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

How could well-meaning and highly educated How could well-meaning and highly educated health professionals, working in their usual health professionals, working in their usual circumstances with diverse populations of circumstances with diverse populations of patients, create a pattern of care that patients, create a pattern of care that appears to be discriminatory?appears to be 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 providers are Bias – no evidence suggests that providers are more likely than the general public to express more likely than the general public to express biases, but some evidence suggests that biases, but some evidence suggests that unconscious biases may existunconscious biases may exist

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

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

Stereotyping: A DefinitionStereotyping: A Definition

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

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

Stereotyping: RisksStereotyping: Risks

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

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

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

Stereotyping: When Is It in Action?Stereotyping: When Is It in Action?

Situations characterized by time pressure, Situations characterized by time pressure, resource constraints, and high cognitive resource constraints, and high cognitive demand promote stereotyping due to the demand promote stereotyping due to the need for cognitive ‘shortcuts’ and lack of full need for 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 found conducted in actual clinical settings found that doctors are more likely to ascribe that doctors are more likely to ascribe negative racial stereotypes to their negative racial stereotypes to their minority patients. These stereotypes were minority patients. These stereotypes were ascribed to patients even when differences ascribed to patients even when differences in minority and non-minority patients’ in minority and non-minority patients’ education, income, and personality education, income, and personality characteristics were considered.characteristics were 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 likely professionals and trainees were more likely to evaluate a hypothetical patient more to evaluate a hypothetical patient more negatively after being “primed” with words negatively after being “primed” with words associated with African American associated with African American stereotypes.stereotypes.

““Patients” experiencing symptoms of heart Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)disease, from Schulman et al. (1999)

““Patients” experiencing symptoms of heart Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)disease, from Schulman et al. (1999)

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. 

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. While indirect evidence from several lines of research supports this statement, a greater understanding of the prevalence and influence of these processes is needed and should be sought through research.

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.

SUMMARY OF RECOMMENDATIONS

GENERAL RECOMMENDATIONS

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.

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; 

LEGAL, REGULATORY, AND POLICY RECOMMENDATIONS (Continued)

Increase in 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.

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.

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.

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.

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.