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.