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Racial Disparities In Health Care: Justin Dimick And Coauthors’ June Health Affairs Study

June 4th, 2013

Racial disparities in health and healthcare are a persistent and troubling problem for the U.S.  Despite substantial policy efforts to the contrary, racial and ethnic minorities, especially African-Americans, often receive a lower quality of care and have worse outcomes.  The key questions, of course, are why do these disparities exist, and what might we do about them?

Over the past decade, two primary theories have emerged to explain disparities and propose solutions to address them.  The first focuses on issues around cultural competence, and suggests that many of the gaps in care are due to poor communication between providers and patients.  Given the long history of discrimination against black Americans, the cultural competency theory argues that low trust on the part of patients, combined with the ineffective communication and lack of cultural sensitivity, leads to black patients receiving worse care with resultant poor outcomes.  Ultimately, the cultural competency theory begs an approach to health disparities that requires more effective training of providers that care for minority patients.

The second theory of racial disparities in care suggests that the site of care really matters, that disparities are driven by the fact that black patients are more likely to receive care at poor quality hospitals.  There is ample evidence for this theory as well — our prior work showed that care for black patients is highly concentrated among a small number of hospitals and these places generally provide a lower quality of care for all their patients.  This theory calls for a somewhat different set of solutions:  focusing on helping the subset of “minority-serving” providers to improve.

The Dimick Study

Of course, there need not be any contradiction between these two theories and one may suspect that both are likely at play.  It is in this context that we have a terrific new study by Justin Dimick and colleagues from the University of Michigan, in the newly released June issue of Health Affairs, that helps us better understand why black patients generally have higher mortality after major surgeries than their white counterparts, and how we might try to reduce this gap.

Dimick and coauthors began with the observation that we’ve known for some time: that black patients more often receive surgical care at lower-quality institutions (that is, hospitals that have high mortality for both their white and black patients).  What we haven’t known is why black patients end up at lower-quality hospitals.  The conventional wisdom has been that black patients live in neighborhoods with poor quality institutions, and they, like everyone else, usually use the nearest hospitals.  So, Dimick and colleagues sought to test this hypothesis.

Their results?  In fact, they found the opposite:  when it comes to surgical care, black patients are more likely to live near a high-quality hospital with lower mortality rates for all patients.  Yet, surprisingly, they are likely to bypass these institutions to receive care at lower-quality hospitals.  How could this be?  And, what might we do about it?

One might question whether a large part of why black patients receive care at lower-quality hospitals is historical.  Until 1964, hospitals were legally segregated institutions, with most hospitals only caring for white patients and a smaller number caring only for black patients.  Even with the advent of Title VI of the Civil Rights Act, which ended formal segregation in U.S. hospitals, long-standing patterns have proven hard to change.

Doctors who work and serve in predominantly black communities may continue to make referrals to traditional “minority-serving” hospitals.  Patients may choose to go to these institutions because they are familiar with them and may feel more comfortable receiving care there.  Indeed, in my own clinical experience, I have known several black patients to be more likely to seek care at what they perceive to be traditionally ‘black-serving hospitals,’ in spite of the proximity and availability of other, sometimes higher-quality, hospitals. Their rationale had more to do with their comfort and historical precedent than actual hospital quality.

Finally, there is the issue that many of these traditional minority-serving hospitals care for large proportions of patients on Medicaid or with no insurance at all, creating substantial financial stress on their capability to provide high-quality care.

The Path Forward

So given the entrenched patterns of care, the complex issues around doctor referral, patient choice, and hospital financial capabilities to deliver high-quality care, what might we do?  I think the solutions, while appearing quite straightforward, have been hard to implement. Dimick identifies a few, and it’s worth going into greater detail with the hope that they may become a reality sooner rather than later.

First, we can work on improving referral patterns.  It’s possible that doctors who refer black patients to low-quality hospitals are unaware of the consequences of their referrals on their patients’ outcomes.  The Centers for Medicare and Medicaid Services (CMS) could easily send each physician an annual report card about the outcomes of care at the institutions where they commonly refer their patients.  A report card to a cardiologist showing that 80 percent of their patients received surgery at a high-mortality hospital when other, low-mortality hospitals were available nearby may offer an important incentive to change.

Improving referrals is unlikely to be enough and we have to acknowledge that many patients will continue to get treated at low-quality hospitals.  Therefore, we need to simultaneously work to ensure that these hospitals improve.  For things that are largely within the hospital’s control, such as surgical mortality, we should have a national standard and hold every hospital accountable for meeting it.  And this needs to be given teeth, by putting substantial payments at risk for poor patient outcomes.

But large penalties for poor performance are not enough and may worsen disparities if hospitals don’t know how to respond effectively.   CMS needs to help these hospitals get better.  CMS can use its convening power to bring minority-serving institutions together to learn from each other.  With large financial penalties at stake for those who fail to improve, hospitals will be motivated to collaborate.  Asking these institutions to learn from each other is far more likely to generate effective solutions than asking one of these institutions to learn from a wealthy neighbor across town that cares for a very different patient population.

The factors underlying healthcare disparities are many, complex, and shaped by the long history of race relations in the U.S. Luckily, there are concrete actions policymakers can take to make things better. We have broad consensus that the color of your skin should not determine the quality of care that you receive.  Yes, there have been efforts to reduce racial disparities, but they have clearly not been enough.  The time to redouble these efforts is now.

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2 Trackbacks for “Racial Disparities In Health Care: Justin Dimick And Coauthors’ June Health Affairs Study”

  1. Sheala Vast-Binder
    January 19th, 2015 at 9:11 am
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3 Responses to “Racial Disparities In Health Care: Justin Dimick And Coauthors’ June Health Affairs Study”

  1. A. Showers Says:

    While this investigator has highlighted this important issue in a rigorous and well-designed study, it comes as no surprise to those of us on the ground affected by these health disparities, or those of us who see affected patients daily. I’m a physician from an urban area with a large Black population, and I’ve participated in focus groups to discuss health disparities with community members for several years. I have to point out something that this article misses, and that is, that many Black patients simply feel unwelcome in some of the larger, more mainstream medical institutions.

    Besides working on referral patterns and the like, we’d all be well-served by thinking about how we (physicians, nurses, receptionists, etc) treat people who are appear different from ourselves. There is a rich literature exploring how conscious, and much more commonly unconscious bias plays a role in physician decision-making, for example. How do we better train medical students to recognize and manage their own biases? Is this even possible? How can we incentivize this kind of training for those who are already health professionals and ancillary staff?

    So while I’m grateful that this study has brought attention to some of the processes underlying higher surgical mortality for Blacks, the solution to the problem goes beyond referral patterns and improving “minority-serving” hospitals. Truly, we should strive to become “all-serving” institutions, meaning that any patient, regardless of race or ethnicity should feel welcome and treated well.

  2. Jess Holmes Says:

    I agree that this is a terribly complex issue, one that we as a nation need to devote more energy and policy towards amending. Interesting piece, thank you for sharing your insights.

  3. macman2 Says:

    Health disparities is far more complex, but in America, it is explicitly much more a vestige of conscious and unconscious discrimination and vestiges of Jim Crow laws. The social determinants of health offer huge disparities in job opportunities, education, housing, access to transportation, etc. for minorities which have been created over generations of prejudice. Our health care financing system, much tied to employment and much biased against minorities (let the poor have Medicaid) remains a continuation of this discrimination rather than a true universal health care financing system like single payer. Add to this the unconscious bias of providers who classify patients based on insurance status rather than what ails them and we are not surprised that we have such huge disparities in health care.

    Interestingly, more than twenty years ago, the US Armed Forces offered some hope that showed that black and white infant mortality rates can be dramatically equalized when soldiers are offered the same military hospitals and access to care. J Fam Pract. 1990 Mar;30(3):281-7; discussion 287-8; Am J Dis Child. 1992 Mar;146(3):313-6. That we haven’t advanced these lessons to our society and our health system shows how intractable discrimination is.

    There is hope however. It has taken generations of discriminatory policies in order to finally recognize this ugly side of American health care. It will take a radical reformation of every aspect of our society – not just health care financing, but a true belief in the equal worth of every American and their God given right to equal opportunity, if we are to really begin to address health disparities.

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