Addressing racial disparities in health care

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.

Ashish Jha is an associate professor of health policy and management, Harvard School of Public Health.  He blogs at An Ounce of Evidence and can be found on Twitter @ashishkjha.

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  • kjindal

    Why focus on “disparities” rather than poor outcomes for a segment of the population? Would the “disparity-obsessed” fairness police be happier if surgical outcomes for whites were made worse, narrowing the gap?

    In my experience at a large urban private hospital in NY in your old stomping ground of Washington heights (we were undergrads together at one point), some minorities seek out particular providers regardless of reputation, but rather on race. This, to me, is analogous to the reality that the vast majority of blacks voted for Obama, regardless of political ideology or any particular issue

    • Ian Abban Thompson

      Kjindal. AA doc here. I’m not sure I understood the thrust of your comment, but it sounds like you are writing from an uninformed place. Health disparities research has nothing to do with the “pc-police”. No one who is interested in outcomes-related research would be “happier” if outcomes for Whites were worsened to be “in line” with Blacks. Health disparities research receives attention because 1) race-related disparities exist – and there are social costs to their existence. 2) Observed disparities in medical care tell us that something is confounding our efforts to provide highest qualitiy care to the American population irrespective of race/economics. We focus on race/economics because that is where the disparities exist. Simple.

      Might I add, that it is true that some minorities seek out particular providers because of race- and there is a historical element to that preference (yes, white providers historically were not interested in caring for minority populations – I call taht racism you can call that whatever you like). Of course, some White patients also seek out particular providers solely because of race (why they do that is up for debate). The point is we all do that. My hope is that we will all do less of that in the future, and health disparities research describes the cost of these preferences and also suggests these preferences alone aren’t explaining the very real differences in clinical outcomes.

      Lastly, your comment about Blacks voting for Obama is really unnecessary. It doesn’t illuminate your point at all, it simply outs your politics and hints at a rather oversimplified world-view.
      Vast majority of blacks voted for Obama. Vast majority of blacks voted for Clinton. Vast majority of blacks voted for Al Gore. Blacks vote for democrats. Blacks have run as republicans, and received very little AA support. Do blacks feel pride at Obama’s election – yes. I suspect some whites did as well. But please put the “race card” away. Blacks voting for Obama is a political thing – not a race thing. I hope your cultural competency as a physician is more nuanced than your politics.

      • kjindal

        I’m sorry you misunderstand my point. I am not denying the existence of racism (not that it should matter, but I’m not white). It’s shameful that you’re trying to portray me as racist, particularly in the last paragraph. If you were to look at and comprehend the numbers, and know a little about statistics, then even after adjusting for the impact of party (democrat vs republican) blacks disproportionately voted for Obama.

        What I am saying is that we should take the lowest decile (or whatever proportion you want) of outcomes and do our best to lift those results, regardless of race (or “disparities between races”, which is really just a euphemism for race).

        Many are of the opinion that anyone who thinks/votes against Obama is racist. That, to me, is sheer racism.

        • Ian Abban Thompson

          I need to apologize. 88% in 2004 of 14 million AA is statistically significantly different from 95% of 16.3 million AA. But, allow me to complicate the discussion a bit further. In 2004 88% of Blacks vote democrat. In 2008 7% more blacks vote democrat (95% of blacks vote for BO). It
          still a gross mischaracterization to say that “blacks” voted for Obama because
          of race. A more accurate statement would
          be to say that a minority of blacks (7
          percent to be exact) likely voted for Obama because of race. However upon further reflection even that statement lacks credibility. You asked “What else is this than about race” –
          Here are some possibilities….

          That 7% who we presume would typically vote republican were A)motivated by historicity of the event. B) motivated by Color-allegiance/race -as u suggest or C) sufficiently unimpressed with Mccain’s Christian imprint, that they voted according to their true political preferences rather than religious worldviews. (The differences between Mccain and Obama’s
          Christian worldview are barely discernible – unlike the differences between the Christian worldviews of Bush and Gore). I haven’t seen any data teasing this possibilities apart. Until that happens, statements like the one
          you made, at face value, seem rather obvious, but in fact they aren’t supported by the data. I’ve read some of your other posts. You seem like the kind of Doc who would be aware of these
          complexities, so I thought that you were race-baiting in your oversimplication.

          Your other point however is well made. Why disparities exist around Columbia is a difficult question. Freq these world class institutions seem to have relatively miniscule effect
          on access and outcomes of neighboring urban populations. Hopkins in Bmore, CCF in Cleveland, etc. I would ask: Your suggestions are sensible, but why remove the racial/class analysis out of the equation altogether. Couldn’t we employ your approach while also continue to examine the role of race. Don’t you think minority patients would be more comfortable accessing hospitals that have shown interest negotiating the very real racial dynamics that
          inform patient behavior. I don’t thnk a “color-blind” approach inspires any confidence in those persons of color who disproportionately fill the decile/quintile we have been discussing.

  • maggiebea

    Then there’s the problem of entrenched racism at every level. In many institutions we can observe that the patient who ‘talks like the man on the six o’clock news’ routinely gets seen sooner in the ER and gets more info from each professional than the patient whose speech is more laid back. We can observe that staff (of every color) routinely voice assumptions about patients based on the staff’s perception of the patient’s socio-economic condition and probable habits. This can be as glaring as the presumption that a patient is ‘drunk’ rather than ‘having a stroke’, or as hard to see as the assumption that the patient’s obesity is solely a result of dietary choices.

  • Suzi Q 38

    I remember a physician (now R.I.P.), Elsie Giorgi.
    Her practice was in Beverly Hills, but she loved to drive across town and work in the poorer hospitals. She consistently volunteered her time to make health care better for the poorer patients, if only for a day. I know that there were many others, but I have never forgotten her.

    I remember seeing the vast differences in the hospital settings from one area of town to the next.
    I had to acknowledge at a young age that “money is power.”
    I also thought about the hospital in the less advantaged area of town:
    “Do the patients know how bad it is here?”
    The attitudes of some of the doctors and nurses, who knew they were serving a certain population that were grateful and had little choice in the matter. Maybe they knew that nothing they could do would change a thing.

  • Victor L Scott

    Dr. Jha: Those who choose to believe that the reason for the racial disparity in Health Care is due to the aforementioned postulates that you discussed, are simply folks willing to stick our heads in the sand and not believe that we still live in a society with racism. In my 35 yrs since admission to Medical school I have seen racism expressed over and over again: for instance a black child is shot and the team awaits the arrival in the ER, and far too often I have heard comments such as: “oh it must be another gang banger” yet in this instance I am describing, the patient arriving in the ER is 6 yrs old and was sitting in moms car going to school when he was hit by a stray bullet. Not only have I seen these events on numerous occasions but also lived it my self only 2 yrs ago when an endocrinology consultant who came to my room, told me to “shut up as he knew what was wrong with me”- yet there I lay in bed a Board certified Internist/Anesthesiologist/Intensivist , and I am being told to shit up despite the fact that I already knew my diagnosis which later he conceded and was forced to believe.

    The reality is that we all, including you have “implicit bias” which we acquire from our parents and environment we grow up in whether rural or urban or beyond the US. I suggest if you have not gone to the Web sit at Harvard to take the test that was created to test for individual implicit bias that you may want to do so. Not all us blacks live in poor neighborhoods without access to healthcare or access to only some of the poorest healthcare networks. Studies such as those from NJ regarding population demographic usage of health networks can be extrapolated to the entire minority population of the USA. Moreover the work done with medical Students that demonstrates cognitive dissonance cannot be ignored as currently $415 Billion per year is spent wastefully in health care due to racial disparities in Health Care

  • Bob

    I am unaware of the existence of “black hospitals” and suggest that those who didn’t live in the time or know hospital history may have this confused with health care economics including insurance.

    There is good reason hospitals are called institutions, as their original purpose was to segregate the sick [physically and mentally] from the well in society. The poor which were mainly immigrant minorities filled hospitals which were laboratories in which mainly white physicians and nurses “trained” on the poor, and treated the rich and did operations at the patients home until the poor had better outcomes than the rich! This caused separate private hospitals to be established in which doctors could be sued whereas those in public ones were barred until 1954 when charitable immunity ended as did education segregation in the Brown v. Education case.

    To believe this theory one would have to accept that whites wouldn’t treat African Americans who then were concentrated in large cities and counties which operated their own public hospitals. If racism existed how did segregated black hospitals populate the hospitals and find the physicians and nurses if public insurance didn’t cover them, until the next year when Medicare and Medicaid were passed?
    For the theory to be accurate you would have to show a list of black hospitals, staffed only by blacks physicians and nurses that only treated uninsured blacks patients until they were referred to as African Americans.

  • Bob

    I thought we were talking about history, which I contend started long before 50 years ago, when survival was more important. As you may know one of the first hospitals only started after the civil War in Boston as a Women’s institution that tried to cause physicians to be certified and graduated the first black woman physician. Hospitals and doctors prior to 1865 just didn’t exist.
    As to African Americans being discriminated against back then, my point is that they were not alone through the years, and most had no access including indentured servants and any not able to pay. The same can be said about the American Indians who caused the Indian Health Service.
    As to your suggestion that Hospitals were formed specifically for African Americans rather than economic reasons I suggest your sample is misleading, in my opinion as even today economics is what holds people back from healthcare more than any other factor including race, and insurance may or may not be the deciding factor.
    Who takes care of the 30 million “new” poor under ACA, probably a lot of whom are African Americans, Latinos an other minorities? If they aren’t cared for do we blame Jim Crow?

  • http://www.twitter.com/alicearobertson Alice Robertson

    Are you sure the ACA has reached it’s goal? If we insure more healthy college kids, but lose many people who have been put down to the 30 hours and below standard…..maybe it, ultimately, levels out? And so many states being (probably rightfully) uncooperative one wonders about the stats (I was reading The Atlantic today because we know July 1 is supposedly that scary new resident’s day. Different studies show different data about whether we should be scared or not…and I have read different data on the ACA and how many are actually helped…hence why I am typing here:)

    I thought years ago the rich avoided hospitals and got their care at home? Of course, we know in the era you are discussing hospitals were some pretty scary places. We know that at one point doctors would walk from an autopsy and deliver a child and the infant mortality rate was horrible. The simple act of hand washing saved a ton of lives, but it wasn’t always practiced.

    Gosh… in a simple world….if a simple act of hand washing could just solve the problem of racism v victimhood (real or perceived) wouldn’t life be grand?!:)

    • SBornfeld

      I know the ACA has not reached its goal, but in fairness, maybe we should wait until it is fully implemented to pass judgment.
      Of course, since Republicans have already forced a 1-year delay in the employer mandate, and continue to fight the individual mandate (and in fact the entire bill) there will be plenty of blame to go around if it fails.

      • http://www.twitter.com/alicearobertson Alice Robertson

        Wait a minute didn’t the Democrats just give employers a pass (just rewriting laws as they please)? Many are the same employers who just knocked 10 hours a week off employees and took their insurance. Employer’s shouts of joy were resounding. So, I don’t think we have to wait until it’s full implemented to see the damage (but some drugs in the interim may be nice:). But then again I have my magazine opened up to an article about Lipstick on the Obamacare Pig:) A lady is holding a sign that she has coverage but can’t get treatment. I like to read from both sides and subscribe to some really radical mags (Mother Jones is a riot until you realize they are serious:)

        But you are honest and admitted you desired a single payer system and I will be honest and share that after living the in UK and my husband living in Canada I don’t like those systems either. I have a daughter with cancer and both of those systems have a much higher likelihood of killing my daughter with waiting lists. I think single payer systems are fabulous for things that usually get better on their own (great at temporal depression treatment, the flu, strep throat, etc.). But serious ailments and awaiting a specialist just terrifies the seriously ill. And even the more successful countries are going bankrupt over it and adding more and more fees.

        I think we both agree something needs done, but I just gotta say the road we are on is treacherous, and because I have teens working with people who are losing their insurance specifically because of the ACA I find it hard to blame just Republicans. The Democrats screwed the whole country by not reading something they voted on. And now many of them are horrified at their error. It’s simple a mess in the legislature and the medical system.

  • Bob

    My definition of hospitals are buildings where people went to survive and leave, not places where people went to die so as to not contaminate the populace. If you meant these the Marine Naval Hospitals and the quarantine needs to place infected people in “garbage pits” goes back to the population of every nation.

    Then as now, Kings, Emperors, Priests and the high positions of power got better treatment, as government personnel do. The VA under financial pressure focuses on “wounded warriors” of Afghanistan as even Iraq has been put behind. Check on the vets of WWII, Korea, Vietnam and see how they are treated, whether African American of with any other background.

    Discrimination is colorless, now as always and I suggest the biggest today is age, three times that of African Americans and twice as large as Latinos, which are a proportionately included.

    While I am on the “other side” of your argument, you’ll not be surprised that I agree with you on the ACA, but will be shocked in my agreement that HC should be universal. but it can’t be for two simple reasons; there aren’t enough caregivers and money as the government won’t stop waste, fraud and abuse, now at a trillion dollars a year and climbing as we cover more people in the ACA, which means we have to cut funds spent on those with care now, by increasing taxes and decreasing education funds!

    • SBornfeld

      Bigotry is bad. That’s my opinion, you’re entitled to yours. If you think discrimination is “colorless”, I don’t think there’s anything more to discuss.

      • Bob

        How about the White Africans in Egypt, Libya, Algeria, as well as Palestinians, Jews, Lebanese and Syrians in the Middle East, and Iraq, Iran, Pakistan and Afghanistan: all of whose US immigrants don’t need “American” placed ahead of where they’re from. The same is true in Asia with China, Tibet, Japan we call Orientals as the Nations of South and Central America we group together and call Latinos.

        In Europe where should I start they’ve had so many conflicts, wars and “mergers” with redrawn borders; And the same is true in Asia and South and Central America countries.

        Most of this has subsided except in Arab and North African Nations. But in African Nations populated by dark skinned peoples, discrimination between tribes and countries have been continuous through the ages. You do remember the missed story by US News during the Clinton years where 500,000 in Rwanda were slaughtered, don’t you?
        Bigoted is; intolerance toward those who hold different opinions from oneself. and while we agree about many things, your belief that only black African Americans have been and continue to be the only ones discriminated against.
        Guess you’ve never been to Africa or anywhere else in the World and can’t win arguments so declare victory and leave the discussion.

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