Widespread Racial and Ethnic Disparities in US Health Care

WASHINGTON—Well-documented racial and ethnic disparities exist in health care even among individuals with the same income and health insurance, and a significant part of the problem lies with the health care system and its professionals, according to a report by the Institute of Medicine (IOM).

"Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases," said Alan R. Nelson, MD, who chaired the committee that wrote the report. "And because death rates from cancer, heart disease, and diabetes are significantly higher in racial and ethnic minorities than in whites, these disparities are unacceptable."

Surprise and Shock

He described some of the committee’s 15 members as surprised, even shocked, at the amount of evidence documenting the disparity problem. "We were not unaware of the extent of the disparity. We were surprised at the breadth and depth of the evidence," said Dr. Nelson, who is special advisor to the chief executive officer of the American College of Physicians-American Society of Internal Medicine and a former president of the American Medical Association.

Determining the extent of excess mortality among minorities resulting from differences in care was impossible, but the preponderance of evidence demonstrates disparities across a number of diagnostic and treatment procedures, said Joseph R. Betancourt, MD, a senior scientist at Harvard Medical School’s Institute for Health Policy.

He cited, as one example, a 1999 study by epidemiologist Peter B. Bach, MD, of Memorial Sloan-Kettering Cancer Center, and his collaborators, which looked at racial differences in the treatment of 10,984 patients with resectable stage I/ II non-small-cell lung cancer.

"African-Americans underwent surgery for resectable lung cancer considerably less often," Dr. Betancourt said. "The African-American patients who did undergo surgery had the same mortality rate as the whites who had surgery."

Co-vice chair Martha N. Hill, PhD, noted that health care disparities also are pervasive across the country by sex, age, and a variety of other factors. "We think it is a serious moral issue that requires we all pay attention," said Dr. Hill, director, Center for Nursing Research, Johns Hopkins University School of Nursing.

Congress requested the report, titled "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" (available at

www.nap.edu

). It asked the IOM, part of the National Academy of Sciences, to assess the racial and ethnic differences in patients’ quality of health care that were not attributable to known factors, such as access to care, ability to pay, or insurance coverage.

Five Key Findings of the IOM Report on Health Care Disparities in the US

Racial and ethnic disparities in health care exist even when insurance status, income, age, and severity of conditions are comparable.

These differences occur in the context of broader historic and contemporary social and economic inequality, and persistent racial and ethnic discrimination in many sectors of American life.

Many sources—including health systems as a whole, health care providers, patients, and health care plan managers—contribute to racial and ethnic disparities in health care.

Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care.

Racial and ethnic minority patients are more likely than white patients to refuse treatment, but the differences in refusal rates are generally small and do not fully explain health care disparities.

In releasing the report with four other committee members at a press conference, Dr. Nelson emphasized five key findings.

"This report is not just for the American people. It is a wake-up call for every health care professional because the health care community in the United States is unaware of the extent to which these disparities exist across such a broad range of medical procedures," said David R. Williams, PhD, professor of sociology, University of Michigan.

Role of Stereotyping

Committee members spent some time discussing the meaning and assessing the role of stereotyping in patient care. Dr. Betancourt defined it as taking certain perceptions about groups and applying them to individual patients.

"Many research projects have been done on the nature of stereotyping and bias," Dr. Williams said. "The stereotyping process is both an unconscious and automatic process. It means that many individuals who do not personally express prejudiced attitudes, who believe in principles of equality, and who are committed to egalitarian values will nonetheless, because they hold negative stereotypes, unconsciously treat patients as stereotypes." For this reason, he added, "we cannot rely on the good intentions of health care providers because these processes will occur even in the presence of good intentions."

Time pressures, particularly those imposed by managed care systems, apparently contribute to the racial and ethnic discrepancies, as does clinical uncertainty, the report said. It notes that when symptoms are unclear and physicians have difficulty making a clear-cut diagnosis, they are trained to place greater emphasis on prior expectations about a patient’s condition based on age, gender, socioeconomic status, race, or ethnicity.

The committee did find a small number of studies that supported a greater rate of treatment refusal by minorities vs nonminorities. "However, if you look at those findings, it is very clear that much of the time, the minority patients will say they did not understand the treatment choices, and that may have contributed to their refusing treatment," said co-vice chair Risa Lavizzo-Mourey, MD, senior vice president of the Robert Wood Johnson Foundation.

Recommendations

The IOM committee also concluded that health care disparities are partly the result of a complex, often fragmented, and economically driven health care environment. It urged legal, regulatory, and policy interventions to solve the problem, and specifically recommended:

• Ending the fragmentation of health plans along socioeconomic lines—a situation in which many minorities wind up with lower-end health care plans—and ensuring that people in publicly funded HMOs have the same managed care protections as those in private HMOs.

• Increasing the number of racial and ethnic minorities among US health professionals.

• Giving more resources to the Office of Civil Rights within the Department of Health and Human Services to investigate and enforce civil rights violations.

• Promoting consistency and equity of care through the use of evidence-based guidelines.

• Structuring payment systems to ensure an adequate supply of services to minority patients and to limit provider incentives that may promote disparities.

• Enhancing communications and trust between patients and providers by financial incentives that reduce barriers and encourage the use of evidence-based decision-making.

• Promoting the use of language interpretation services when needed.

• Supporting community health workers (for such things as helping patients navigate the health care system) and multidisciplinary treatment and prevention care teams.

• Implementing education programs to increase patients’ knowledge of how to best access care and participate in treatment decisions, as well as cross-cultural education programs aimed at current and future health professionals.

• Collecting and reporting data on health care access and use by patients’ race, ethnicity, socioeconomic status, and, where possible, primary language.

• Including measures of racial and ethnic disparities in assessing provider performance.

• Monitoring progress toward the elimination of health care disparities.

"The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them," Dr. Nelson commented.