WASHINGTON, DC—Minority patients are more likely to receive lower-quality health care even when their income and health insurance coverage are comparable to those of whites, according to a new report from the Institute of Medicine (IOM). The report, prepared at the request of Congress, was released at a news briefing here.
While previous reports—including a 1999 document by the National Cancer Policy Board—have highlighted problems of unequal health care in America, the new IOM report is one of the broadest and most comprehensive on the topic, covering all diseases and conditions.
It is also different in that many previous reports focused on access to health services. This IOM report, called “Unequal Treatment,” found that even when access to services is comparable, health treatment is not. To correct the situation, the committee made a number of specific recommendations (see box).
Findings from studies reviewed for the report include the following:
▪ African American women with breast cancer were less likely than white women to receive progesterone-receptor assays, less likely to receive radiation therapy in combination with radical/modified mastectomy, and less likely to receive rehabilitation support services following mastectomy.
▪ For all age groups in 1991, twice as many blacks as whites (12.5% vs. 6.6%) received no treatment for prostate cancer.
▪ African American cancer patients were less likely to receive post-treatment surveillance care.
▪ African Americans had a 63% greater probability of being untreated for cancer pain relative to whites.
“Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care,” said Alan R. Nelson, MD, Chair of the IOM committee that wrote the report and Special Adviser to the Chief Executive Officer of the American College of Physicians-American Society of Internal Medicine.
“Some of us were surprised and shocked at the extent of the disparities,” added Dr. Nelson, who is also a former President of the American Medical Association.
Uneven Playing Field
“We have a health care system that is the pride of the world, but this report documents that the playing field is not even,” said IOM Committee member David R. Williams, PhD, Professor of Sociology and Senior Research Scientist at the Institute for Social Research at the University of Michigan in Ann Arbor. “This report is a wake-up call for every health care professional.”
Dr. Williams said the patterns of inequality that occur in the health care field are consistent with what occurs in other segments of society. Dr. Nelson agreed, saying that racial and ethnic biases are not more prevalent in physicians than in US society in general, but rather reflect society at large.
In some cases factors revolving around the communication process during a physician-patient encounter may contribute to racism in medicine, said committee members. Time constraints and productivity pressures may play a role in patient stereotyping—which is a “normal cognitive process,” said committee member Joseph R. Betancourt, MD, Senior Scientist at the Institute for Health Policy and Director for Multicultural Education at Massachusetts General Hospital.
This stereotyping, a kind of mental shorthand, may include assumptions about a patient's ability to comply with prescribed treatment, for example.
In medicine, verbally proficient patients tend to receive better care. Studies show that “physicians and other health care providers are more comfortable interacting with people like themselves—highly educated, articulate individuals,” said IOM Committee Co-Vice Chair Risa Lavizzo-Mourey, MD, Senior Vice President of the Robert Wood Johnson Foundation.
“A person's culture comes right to the bedside,” added the other Co-Vice Chair, Martha N. Hill, PhD, RN, Professor and Director of the Center for Nursing Research and Interim Dean at Johns Hopkins University School of Nursing.
The Committee found that racial and ethnic minority patients are more likely than white patients to refuse treatment, but that differences in refusal rates are not pronounced enough to explain health care disparities fully.
In some cases, differences in refusal rates can be explained on the grounds that minority patients say they did not fully understand their treatment choices, Dr. Lavizzo-Mourey noted. The way their questions were posed and the answers they received may have affected their treatment decisions.
The IOM committee's findings are not news to Lucille C. Norville Perez, MD, President of the National Medical Association, which represents African American physicians. In March 2001 the Association released a consensus paper called “Racism in Medicine and Health Parity for African Americans: ‘The Slave Health Deficit.’”
Dr. Perez noted that since 1907 the organization (which was established in 1895) has continuously reported on health care disparities in its journal. One of the group's consensus papers found that racism in medicine and health care is “deeply ingrained in the fabric of the US medical-social culture,” and has contributed to poorer health status and outcomes for African Americans. Dr. Perez commended the IOM committee for its courage in bringing its findings to light.
Differing Perceptions about Racism
Highlights from the Kaiser Family Foundation's forthcoming National Survey of Physicians show that white and minority physicians differ in their perceptions of racism as a problem in medicine.
Some 69 percent of physicians said that overall the health care system rarely or never treats people unfairly based on their race or ethnicity, but 77 percent of African American physicians surveyed believe race and ethnicity affect how people are treated at least somewhat often.
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IOM Committee's Recommendations
To equalize medical treatment for minorities, the IOM committee made the following recommendations. The nation needs to:
▪ Increase awareness of racial and ethnic disparities in health care among the general public, physicians, and other key stakeholders.
▪ Avoid fragmentation of health plans along socioeconomic lines.
▪ Strengthen the stability of patient-provider relationships in publicly funded health plans.
▪ Increase the proportion of racial and ethnic minority physicians and other health care professionals (over the past 30 years, the percentage of black physicians has risen very little, from 3.5 to 3.9 percent).
▪ Extend the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees.
▪ Provide greater resources to the Office of Civil Rights of the US Department of Health and Human Services to enforce civil rights laws.
▪ Promote consistency in health care through the use of evidence-based practice guidelines.
▪ Provide financial incentives to medical practices that build trust by reducing barriers to services and using evidence-based guidelines.
▪ Support the use of language interpretation services where community need exists.
▪ Implement patient education programs to increase patients' knowledge of how to best access care and participate in treatment decisions.
▪ Integrate cross-cultural education into the training of all current and future health professionals.
▪ Collect data on health care use, access, and services by patients' race, ethnicity, socioeconomic status, and, where possible, primary language.
Minority Health and Disparities Research and Education Act
Two years ago Congress passed the Minority Health and Disparities Research and Education Act, which was signed into law in November 2000. The legislation expands research and education on the various factors contributing to health disparities in minority and medically underserved populations, said Sen. Bill Frist, MD (R-TN), a co-sponsor of the bill with Sen. Edward Kennedy (D-MA).
“As we begin to better understand the root causes of these disparities, it's imperative that we target research, improve education and public awareness, increase prevention measures, and provide better access to care,” Senator Frist commented in a statement about the new IOM report.