Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD

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The California EndowmentA Partner for Healthier Communities

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Mobilizing to Eliminate Health Disparities

2003 Ethnic Physician Summit

Carolina Reyes, MD

The California Endowment

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• Racial/Ethnic Disparities in Health• The IOM Report on Racial/Ethnic Disparities in

Health Care: “Unequal Treatment”• Major Findings and Recommendations

Outline

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• Among the nation’s most serious health care problem (IOM 2002)

• Approximately 30 percent of Americans are racial or ethnic minorities and even greater diversity of the US is expected.

• Healthcare quality and health outcomes across ethnic and racial populations is disturbing.

Disparities in Health Care

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• Despite health interventions that have improved the

overall health of the majority of Americans, minorities

have benefited less from these advances (NHLHI)

Racial/Ethnic Disparities in Health

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Cardiovascular Disease Death Rate, 1999

Deaths per 100,000 population

263.3

336.5

176.2 179.6154.1

050

100150200250300350400

WH

ITE

AF

RIC

AN

AM

ER

ICA

N

HIS

PA

NIC

AI/

AN

AS

IAN

/PI

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Cancer Death Rate, 1999Deaths per 100,000 population

199.8

254.3

122.1 126.4 125.3

020406080

100120140160180200220240260280300

WH

ITE

AFR

ICA

NA

MER

ICA

N

HIS

PA

NIC

AI/

AN

AS

IAN

/P

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Diabetes-Related Death Rate, 1999

Deaths per 100,000 population

22.8

50.1

33.6

50.3

18.4

0

10

20

30

40

50

WHITE AFRICANAMERICAN

HISPANIC AI/AN ASIAN/PI

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• Social Determinants– Education, geography, environment, housing, employment

• Access to Care– Insurance, continuity of care

• Health Care– Health systems and the medical encounter

What Leads to Disparities in Health?

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• Within Medicare:– Differential utilization based on race for:

• Mammography (Gornick et al.)• Amputations (Gornick et al.)• Influenza vaccination (Gornick et al.)• Lung Ca Surgery (Bach et al.)• Renal Transplantation (Ayanian et al.) • Cardiac catherization & angioplasty (Harris et al,

Ayanian et al.) • Coronary artery bypass graft (Peterson et al.)• Treatment of chest pain (Johnson et al.)• Referral to cardiology specialist care (Schulman et al.)• Pain management (Todd et al.)

Racial/Ethnic Disparities in Health Care

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• Private, independent non-profit Institute of National

Academy of Sciences

• Examines issues related to health policy, health care,

education and research

• Convenes “mixed” expert panel for deliberations (6-24

months) and findings to Congress and the public

Congressional Action: Institute of Medicine Report

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Study Charge

• Determine presence and extent of racial/ethnic disparities in

health care not attributable to access

• Evaluate potential sources of disparities including the role of

bias, discrimination, and stereotyping at the individual,

institutional, and health systems level

• Provide recommendations regarding interventions to

eliminate racial/ethnic disparities

IOM’s Unequal Treatment

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• Eliminating disparities in health has become a national priority of the NIH, DHHS

• Any effort to eliminate disparities will be hindered by an incomplete understanding of the social context of individuals.

Why Study Ethnic Racial Bias?

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• Neglecting study of the health impact of bias, discrimination means that explanations for and interventions to alter population distributions of health, disease, and well-being will be incomplete, if not outright harmful.

Why Study Racial Bias?

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• This area of work is fraught with controversy because the exposure raises important themes of accountability and human rights.

• It is no more less germane than for research on any other social determinant.

• It is political and unscientific to exclude this study from legitimate scientific inquiry and discourse.

Why Study Racial Bias?

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• Explicitly naming a long-standing problem long recognized by those affected has the potential to galvanize or catapult inquiry and action– “The Battered Child Syndrome” by C. Henry

Kempe– Domestic Violence

The Unnamable Is Named

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• Once named it becomes less nebulous and more tangible

• Bolstered with the belief that with more rigorous documentation, analysis and resources – it could ultimately be rectified

The Unnamable Is Named

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Non-Minority

Minority

Difference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and

Regulatory Climate

Discrimination: Biases andPrejudice, Stereotyping, and

Uncertainty

Disparity

Qua

li ty

o f H

e al th

Car

e

Defining the Issues:

Differences, Disparities, and Discrimination in Populations with Equal Access to Health Care

Populations with Equal Access to Health Care

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Sources of Data

• Literature Search– Over 600 papers reviewed

• Commissioned Papers– Disparities, Legal Issues, Ethical Issues, Data Issues, etc.

• Expert Testimony– Technical expertise and representation

• Public Workshop– Professional and Advocacy Perspectives

• Focus Groups– Both providers and patients

18 Month Process

IOM’s Unequal Treatment

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Major Finding

Racial/Ethnic disparities consistently found across a wide range of health care settings (managed care, public/private hospitals, teaching/community, etc.), disease areas (CVD, Ca, HIV, DM, etc.) and clinical services, even when various confounders are controlled for (i.e. SES, stage of presentation, comorbidities)

IOM’s Unequal Treatment (www.nap.edu)

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Specific Findings• Racial and ethnic disparities in health care exist and, because

they are associated with worse outcomes in many cases, are unacceptable.

• They occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life.

• Many sources – health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care.


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Specific Findings

• Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.

• Racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences in refusal rates are generally small, and do not fully explain healthcare disparities.


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“Sociocultural differences between patient and physician influence communications and

clinical decision-making.” Eisenberg, 1979

Physician-Patient Communication

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Linking Communication

to Outcomes

How do we link communication to outcomes?

Communication

Patient Satisfaction

Adherence

Health Outcomes

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“Medical decision-making can be as much a function of who the patient is as

much as what the patient has.”

Mckinley et al., 1996

Physician Decision-Making

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• Focuses on questions such as:– How do we develop perceptions and

judgments of others?– What factors influence the way we form

beliefs?– How do we use “social knowledge” to make

decisions?

Physician Decision-Making Social Cognition

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• Characteristics of the Patient– Age, Sex, SES, Race/Ethnicity, Insurance,

Individual patient factors• Characteristics of the Physician

– Specialty, Level of Training, Background• Features of the Practice Setting

– Organization of Practice, Compensation, and expectations of productivity

Factors Affecting Physician Decision-Making

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• Automatic aspects; groupindividual• “Cognitive Misers”cognitive shortcuts to save

resources; principle of “least effort”• Primal->race, gender, age• Activated most when:

– Stressed– Under time constraints– Multitasking

Social Cognitive Theory: Stereotyping

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• Built on the IOM report on Crossing the Quality Chasm in 2001– One of the six goals to raising the overall

quality of the nation’s healthcare• Clearly stated that racial discrimination is

intolerable by law• Contrary to the moral creed and health care

ethic

Disparities in Health Care

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• Arguments date back a century and a half ago• The task at hand is to bring the knowledge and

methods available in our generation to the pressing explicit public health problem of persistent racial/ethnic health care disparities.

Is This Inquiry New?

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Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Institute of Medicine

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Insanity is when we keep doing the same thing and expecting a different result.

-Albert Einstein

How Do We Begin To Address These Disparities?

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• Lack a robust tool bag of interventions• Significant disparity in the racial ethnic

diversity among health professionals.• Language barriers are a major challenge.

Tool Bag of Interventions

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General Recommendations:

• Increase awareness of racial and ethnic disparities in health care among the general public and key stakeholders

• Increase health care providers’ awareness of disparities.

Summary of Recommendations

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• De-fragmentation of Healthcare Financing and Delivery

• Avoid fragmentation of health plans along socioeconomic lines

Legal, Regulatory and Policy Recommendations

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Strengthening Doctor-Patient Relationships:

– Take measures to strengthen the stability of patient-provider relationships in publicly

funded health plans


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Improve the Diversity of the Workforce:

Increase in the proportion of underrepresented U.S. racial and ethnic minorities among health professionals;


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Patient Protections:

Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees


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Civil Right Enforcement:

Provide greater resources to the U.S. DHHS Office of Civil Rights to enforce civil rights laws.


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Evidence-Based Cost Control:

Promote the consistency and equity of care through the use of evidence-based guidelines

Health Systems Interventions

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Financial Incentives in Health Care: • Structure payment systems to ensure an

adequate supply of services to minority patients, and limit provider incentives that may promote disparities;

• Provide financial incentives for practices that Enhance patient-provider communication Encourage evidence-based practice


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Interpretation Services:

• Promote the use of interpretation services where community need exists

• Community Health Workers

• Support the use of community health workers


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Multidisciplinary Teams:Implement multidisciplinary treatment and preventive care teams that help coordinate and streamline care


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Patient Education and Empowerment:

Patient education programs should be implemented to increase patients’ knowledge of how to best access care and participate in treatment decisions.

Cross-Cultural Education in Health Professions: Integrate cross-cultural education into the training of all current and future health professionals.


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DATA COLLECTION AND MONITORING:

Collect and report data on health care access and utilization by patients’ race, ethnicity, socio-economic status, and where possible, primary language;

Include measures of racial and ethnic disparities in performance measurement;


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DATA COLLECTION AND MONITORING:

Monitor progress toward the elimination of health care disparities;

Report racial and ethnic data by OMB categories, but use subpopulation groups where possible


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NEEDED RESEARCH:

Conduct further research to identify sources of racial and ethnic disparities and assess promising intervention strategies, and; Conduct research on ethical issues and address barriers to research of disparities in care


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• Acutely aware of the value laden and sensitive nature of the subject

• Disparities in healthcare may be reflective of inequalities in other aspects of American life

• The real challenge is embracing and acting on these recommendations

• Requires a broad and sustained commitment from all of us

Conclusions

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• National dialogue– Professional organizations– Catalyst for adding cultural competency

under the rubric of quality care– Health plans are developing strategies to

address race/ethnicity disparities

What has been the Impact of the IOM report to date?

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• Equity is defined as “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status”

• For populations, equity means reducing disparities in the use of health care services that are related to personal characteristics

Guiding the National Healthcare Disparities Report

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• Health Care Quality– Safety– Effectiveness– Patient Centeredness– Timeliness


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• Severe morbidity and mortality from disease is always a tragedy.

• Preventable morbidity and mortality is unjust.


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• Immense challenges to improving our healthcare system for many populations experiencing unequal treatment.

• Immense commitment– Strategize with colleagues– Create new partnerships– Explore our own role towards

elimination of disparities

Conclusion

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• Teamwork across expertise– Building coalitions– Trusting relationships

• Tenacity• Realistic• Hopeful• Keep our attention focused on the possible

Sustained Policy Change

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The California EndowmentA Partner for Healthier Communities

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Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD