Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare

Institute of Medicine

Do you think the average African American is better off, worse off, or just about as well off as the average white person in terms of access to health care?

70 60 50 40 30 20 10 0 Whites Source: Morin, 2001 African Americans Better Off About the Same Worse Off No Opinion

Media Response to

Unequal Treatment

USA Today

, March 22 “Racial Bias in Health Care” “In unassailable terms, the report found that even when their insurance and income are the same as those of whites, minorities often receive fewer tests and less sophisticated treatment for a panoply of ailments, including heart disease, cancer, diabetes and HIV/AIDS. By stripping away the pretense that the differences can be explained by minorities' lack of access to timely care, the report should spur doctors and patients to question why racial disparities are tolerated in medicine.”

Media Response to

Unequal Treatment

(cont’d)

New York Times

, March 22, “Subtle Racism in Medicine” “ . . . a disturbing new study by the Institute of Medicine has concluded that even when members of minority groups have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care. Biases, prejudices and negative racial stereotypes, the panel concludes, may be misleading doctors and other health professionals.”

The Washington Post

, March 23, “The Health Care Gap” “Race-based inequities are a sad fact in more than one facet of American life. History has shown how hard they are to overcome. But this week's report paints a picture that cannot be ignored.”

Media Response to

Unequal Treatment

(cont’d) “Racist Doctors? Don't Believe the Media Hype” By Sally Satel

Wall Street Journal

, April 4 “Are doctors prejudiced? According to the media's coverage of a new report by the Institute of Medicine called ‘Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,’ the answer is yes . . . The truth is far less inflammatory than . . . the press would have us believe. The institute's case for prejudice in the March 20 report is weak.”

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.

Caveats – Unequal Treatment



Access (e.g., insurance status, ability to pay for healthcare) is groups the most important predictor of the quality of healthcare across racial and ethnic



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

Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care

Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Populations with Equal Access to Health Care

Evidence 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)

Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et al., JAMA, March 13, 2002 80 70 60 50 40 30 20 Breast Screening Eye Exams Beta Blockers Health Service Follow-up Whites Blacks

Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993 Black White Black-to- White Ratio

Angioplasty (procedures per 1,000 beneficiaries per year) Coronary Artery Bypass Graft Surgery (procedures per 1,000 beneficiaries per year) Mammography (procedures per 100 women per year) Hip Fracture Repair (procedures per 100 women per year) Amputation of All or Part of Limb (procedures per 1,000 beneficiaries per year) Bilateral Orchiectomy (procedures per 1,000 beneficiaries per year) Source: Gornick et al., 1996 2.5 1.9 17.1 2.9 6.7 2.0 5.4 4.8 26.0 7.0 1.9 0.8 0.46 0.40 0.66 0.42 3.64 2.45

What 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