The Health Disparities Gap

Minorities Aren't Getting the Health Care They Deserve

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Cover Story -- May 2004  

By  Ken Ortolon
Senior Editor  

Madisonville family physician Andrew C. Eisenberg, MD, was on call as the backup physician in the local hospital emergency room (ER) one busy March afternoon when a father brought in his 10-week-old son with respiratory problems. The family is Hispanic, and the father didn't speak English. The staff on duty that day didn't speak Spanish, but proceeded with a workup on the child, including a chest x-ray, blood count, and oxygen saturation monitoring.

But it wasn't until Dr. Eisenberg, who speaks Spanish "reasonably well," arrived at the ER a few hours later that a more complete picture of the child's health status emerged.

"I talked to the family and found out that [the emergency room staff] didn't get the same history that I did. They did not learn that the baby was born five or six weeks prematurely, was in an incubator, had respiratory problems then, and wasn't caught up on shots."

Because of the new information, Dr. Eisenberg says, the child was admitted and spent a few days in the hospital.

The incident is a classic example of how culture, language, and other barriers contribute to wide disparities in health outcomes for racial and ethnic minorities. Reports issued by the Institute of Medicine (IOM) in March 2002 and the Agency for Healthcare Research and Quality (AHRQ) in December 2003 documented significant differences that constitute a formidable challenge for U.S. health care.

The AHRQ report shows, for example, that breast and colorectal cancers are diagnosed sooner in whites than in minorities. AHRQ also found that poor patients are less likely to receive recommended diabetes services, that Hispanics hospitalized for acute myocardial infarction are less likely to receive optimal care, and that African-Americans and poorer patients have higher rates of avoidable hospitalizations.

While socioeconomic factors that limit access account for many of the disparities, the reports also found that language barriers, lack of knowledge about minority cultures by health care professionals, and even bias -- conscious and subconscious -- play a significant role in creating disparities.

Is It Prejudice?  

Health professionals have long recognized disparities in health outcomes for racial and ethnic minorities, as well as for the elderly, residents of certain geographic areas, low-income Americans of all ethnicity, and for other groups. However, the IOM report " Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare " drew national attention to the problem.

That report concluded that many factors contribute to health disparities. They include subtle differences in how racial and ethnic minorities respond to treatment; differences in how likely they are to seek treatment; language and cultural barriers; and access to care and ability to pay. However, the report also says that significant differences exist in quality of care and outcomes for minorities even when access and payment are not an issue. That, the IOM concluded, points to some level of prejudice or bias by health care professionals.

"[Al]though myriad sources contribute to these disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care," the report stated.

For example, the IOM pointed to a 1999 study that shows physicians order cardiac catheterization for white and black men and white women at similar rates, but referred black women significantly less often. The IOM report also cited studies that found that physicians rate black patients as less intelligent, less educated, and more likely to fail to comply with medical advice. While the IOM found no direct evidence that health care professionals' biases affect the quality of care, it reviewed various studies that suggest treatment decisions are influenced by race, ethnicity, gender, and other factors.

Dr. Eisenberg, chair of Texas Medical Association's Council on Public Health and its representative on a task force created by the American Medical Association to deal with health disparities, says everyone has biases, no matter how conscientious health professionals think they are in providing care.

"We're all biased to a certain degree based on our upbringing and what we've been through in life. We may apply not necessarily a different standard and not necessarily consciously, but subconsciously, a different set of rules to people based on preconceptions."

Harlingen family physician Adela Valdez, MD, chair of the Texas Health Disparities Task Force, agrees. "The fact is that physicians are probably still exhibiting racial and ethnic and socioeconomic discrimination. I would rather physicians correct this themselves as an organization than have other groups start doing it."

But task force member Jesse Moss, MD, says factors other than bias may play a more significant role in disparities.

"If you look at the data, you could draw the conclusion that medicine is discriminatory toward minorities," said Dr. Moss, an otolaryngologist from San Antonio and a long-time leader in the Lone Star Medical Association. "That would not be a fair conclusion."

Dr. Moss says access to care and patient-physician communication issues such as language barriers or patients' inability to understand and comply with a treatment regimen are critical issues impacting disparities.

Going Beyond Bias  

The AHRQ report built on the IOM report but looked more directly at how socioeconomics impact disparities. AHRQ found that many racial and ethnic minorities and low-income Americans are less likely to have a usual source of care and are less likely to have health insurance.

AHRQ also concluded that higher rates of avoidable hospital admissions by African-Americans and the poor could be explained in part by the fact that they do not receive routine care as often as they should. And, the agency found that opportunities to provide preventive services frequently are missed for certain populations. AHRQ said it is "difficult to tease out" how large a role race, income, and education each play in producing these disparities.

These trends, combined with growing minority populations, present a significant long-term problem for the health of minorities and that of our health care system, as well, the AHRQ concluded.

"Demographic trends indicate that the number of Americans who are vulnerable to suffering the effects of health care disparities will rise over the next half century," the report stated. "Nearly one in two Americans will be a member of a racial or ethnic minority -- i.e., black, Hispanic, Asian, or American Indian -- by the year 2050. Clearly these trends pose a daunting challenge for policymakers and the health care system."

Recognized and Ignored  

Here in Texas , Dr. Moss says, health disparities are "recognized and ignored." But that may be changing. Even before the IOM released its report, Texas lawmakers passed legislation creating the Texas Health Disparities Task Force.

The panel's mission addresses six key topics:

  • Increasing childhood immunization rates among minority populations.
  • Promoting regular physical activity and physical fitness in racial and ethnic minorities.
  • Decreasing obesity among those groups.
  • Reducing tobacco use among minority youth.
  • Promoting responsible sexual behavior among minority youth and adults.
  • Promoting adequate prenatal care among minority women.

The task force is working to maintain or increase funding for Medicaid and the Children's Health Insurance Program (CHIP).

The panel also endorsed prompt payment of health care professionals by health plans and medical liability reforms, such as caps on noneconomic damages. Dr. Valdez says the task force believes those issues have a direct bearing on access to care.

Dr. Valdez says task force members were disappointed that Medicaid and CHIP took serious budget cuts as lawmakers resolved a $10 billion deficit in 2003. And the task force saw its own funding slashed from $40,000 to $10,000 for the current biennium. However, it is pressing forward.

Already, several public and private initiatives are helping to eliminate health disparities in Texas, Dr. Valdez adds.

Among those are efforts of the Paso del Norte Foundation in El Paso to place promotoras in colonias and other underserved communities. Promotoras are community health workers -- often unpaid volunteers -- who provide cultural mediation between minority communities and health and human services systems. They provide informal counseling and social support and culturally and linguistically appropriate health education, advocate for individual and community health needs, and help ensure that people get the health services they need. They have been very vigilant in encouraging screening for cervical cancer, which is prevalent among the Hispanic population, Dr. Valdez says.

Elsewhere, the American Cancer Society has established some best practices for breast cancer screening that have been employed in some areas of Texas where the African-American population was experiencing high rates of breast cancer. Those practices helped those communities develop plans of action to encourage African-American women to see their doctors and get regular mammograms, she says.

"We need to build on these successes," Dr. Valdez said.

Fixing the Problem  

On the national level, AMA and other groups are working to eliminate health disparities. The impetus for the AMA task force arose in part from a memorandum of understanding the association signed with the U.S. Department of Health and Human Services (HHS) about three years ago. They agreed to work together to carry out the goals of the Healthy People 2010 project, says Clair Callan, MD, acting senior vice president for professional standards at AMA. Reducing health disparities is part of that project.

AMA invited representatives of 25 state medical and specialty societies to participate in the task force. At its meeting in October, the group discussed 10 broad areas of concern, including awareness of disparities, cultural diversity, diversity of the professional workforce, cultural competence of physicians, patient-physician communication, and trust.

Among groups represented on the panel are both the National Medical Association and National Hispanic Medical Association; state medical societies from Texas, Michigan, New York, and Illinois; specialty societies representing addiction medicine, pediatrics, emergency medicine, surgery, family practice, and obstetrics-gynecology; the IOM and AHRQ; and the Robert Wood Johnson Foundation. The foundation will provide financial support for various projects.

The task force was scheduled to reconvene in April to narrow its focus to two or three issue areas that could be the target of specific projects.

As AMA is bringing the weight of the medical profession to bear on the issue of disparities, Congress is considering potential legislative solutions to the problem.

Senator Majority Leader Bill Frist , along with Sens . Mary Landrieu (D-La.), Thad Cochran (R-Miss.), and Mike Dewine (R-Ohio) unveiled S 2091, the Closing the Health Care Gap Act, in February. The bill attacks health disparities on multiple fronts.

First, it requires standardized health care quality measures and reporting requirements within federal health programs. Such quality measures would have to be in place for five common health conditions by 2006 and for an additional 10 conditions by 2007. HHS would determine the conditions. The emphasis would be on conditions disproportionately affecting minority populations and would take into account health literacy, primary language, and cultural factors.

The bill also would:

  • Require enhanced data collection by race, ethnicity, and primary language within Medicare and Medicaid;
  • Establish health care access and promotion grants to give disparity populations greater access to and awareness of available health services;
  • Promote professional education, awareness, and training by, for example, increasing funding for centers of excellence in workforce diversity and training; and
  • Authorize demonstration projects to test model curricula and identify additional barriers to culturally appropriate care.

Nick Smith, press aide to Senator Frist, says the bill has not yet begun its way through the Senate committee process. It has bipartisan support and is backed by the National Medical Association, National Hispanic Medical Association, the National Urban League, former Surgeon General David Satcher , MD, and others.

U.S. Sen. Kay Bailey Hutchison (R-Texas) is among those who have signed on as cosponsors.

Neither AMA nor TMA has taken a position on the bill, but Dr. Callan says AMA likely will support it. TMA's Council on Public Health submitted written comments in March, praising the quality measures and increased funding.

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by e-mail at Ken Ortolon.  

Seminar to Focus on Health Literacy

Diagnosing an illness and prescribing a treatment plan is the core of the practice of medicine, but physicians must make sure patients understand and can comply with their instructions for any treatment plan to be effective.

That is the goal of a three-hour seminar on health literacy during TexMed 2004 in Austin.

"Health Literacy: Helping Your Patient Understand" will be presented from noon to 3 p.m. Thursday, May 13, in Room 17B of the Austin Convention Center. Michael E. Speer, MD, and Josie R. Williams, MD, will provide an overview of health literacy, explain goals and objectives to ensure that patients understand health care instructions, identify troubleshooting techniques for common literacy problems, and describe the resources and implementation plan for a health care literacy program.

"Almost half of all patients have difficulty understanding instruction on how to take their medications correctly, manage their chronic or acute illnesses, or even find their way to an outside laboratory or radiology facility for tests," Dr. Speer said. "Twenty-one percent cannot consistently understand the contents of an article or follow a bus schedule. These are the same people who may go for health care to the emergency room instead of a physician's office because someone else will fill out the paperwork required. They cannot."

In some populations, including the elderly and recent immigrants, up to 70 percent will have such difficulties as Dr. Speer described. "Physicians and their office staff can help these patients immensely by adopting some very simple, inexpensive techniques."

According to the American Medical Association, up to one-half of Americans may be at risk for medical misunderstandings, mistakes, excess hospitalizations, and poor health outcomes because of literacy problems or difficulty understanding their physician's instructions. The 1993 National Adult Literacy Survey found that 21 percent of Americans have inadequate literacy and 27 percent have marginal literacy.

The presentation has been approved for 3 credit hours of continuing medical education in ethics.

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