Unequal Treatment: Unequal Treatment: Confronting Racial and Ethnic Disparities Confronting Racial and Ethnic Disparities
in Healthcarein Healthcare
Institute of MedicineInstitute of Medicine
Do you think the average African Do you think the average African American is better off, worse off, or just American is better off, worse off, or just about as well off as the average white about as well off as the average white person in terms of access to health care?person in terms of access to health care?
0
10
20
30
40
50
60
70
Whites African Americans
Better OffAbout the SameWorse OffNo Opinion
Source: Morin, 2001
Media Response to Media Response to Unequal TreatmentUnequal 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 Media Response to Unequal Treatment Unequal Treatment (cont’d)(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 Media Response to Unequal Treatment Unequal Treatment (cont’d)(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.
Access (e.g., insurance status, ability to pay Access (e.g., insurance status, ability to pay for healthcare) is for healthcare) is thethe most important most important predictor of the quality of healthcare across predictor of the quality of healthcare across racial and ethnic groupsracial and ethnic groups
It is difficult – even artificial – to separate It is difficult – even artificial – to separate access-related factors from social categories access-related factors from social categories such as race and ethnicitysuch as race and ethnicity
The bulk of research on healthcare The bulk of research on healthcare disparities has focused on black-white disparities has focused on black-white differences – more research is needed to differences – more research is needed to understand disparities among other racial understand disparities among other racial and ethnic minority groupsand ethnic minority groups
Caveats – Caveats – Unequal TreatmentUnequal Treatment
Non
-Min
orit
y
Min
orit
yDifference
Clinical Appropriateness and Need
Patient Preferences
The Operation of Healthcare Systems and the Legal and Regulatory Climate
Discrimination: Biases andPrejudice, Stereotyping, andUncertainty
Disparity
Qua
li ty
o f H
e al th
Car
eFigure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care
Populations with Equal Access to Health Care
Evidence of Racial and Ethnic Evidence of Racial and Ethnic Disparities in HealthcareDisparities in Healthcare
Disparities consistently found across a wide Disparities consistently found across a wide range of disease areas and clinical servicesrange of disease areas and clinical services
Disparities are found even when clinical Disparities are found even when clinical factors, such as stage of disease presentation, factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are co-morbidities, age, and severity of disease are taken into accounttaken into account
Disparities are found across a range of clinical Disparities are found across a range of clinical settings, including public and private hospitals, settings, including public and private hospitals, teaching and non-teaching hospitals, etc.teaching and non-teaching hospitals, etc.
Disparities in care are associated with higher Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1999; Peterson et al., 1997; Bennett et al., 1995)1995)
Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et al., JAMA, March 13, 2002
20
30
40
50
60
70
80
Percent Receiving Services
BreastScreening
Eye Exams BetaBlockers
Follow-up
Health Service
WhitesBlacks
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)
2.5 5.4 0.46
Coronary Artery Bypass Graft Surgery (procedures per 1,000 beneficiaries per year)
1.9 4.8 0.40
Mammography (procedures per 100 women per year)
17.1 26.0 0.66
Hip Fracture Repair (procedures per 100 women per year)
2.9 7.0 0.42
Amputation of All or Part of Limb (procedures per 1,000 beneficiaries per year)
6.7 1.9 3.64
Bilateral Orchiectomy (procedures per 1,000 beneficiaries per year)
2.0 0.8 2.45
Source: Gornick et al., 1996
What are potential sources of What are potential sources of disparities in care?disparities in care?
Health systems-level factors – Health systems-level factors – financing, structure of care; financing, structure of care; cultural and linguistic barrierscultural and linguistic barriers
Patient-level factors – including Patient-level factors – including patient preferences, refusal of patient preferences, refusal of treatment, poor adherence, treatment, poor adherence, biological differencesbiological differences
Disparities arising from the clinical Disparities arising from the clinical encounterencounter
