Race in Health Care
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SUSAN DENTZER: Doctors have long had a litany of complaints against HMO’s and other managed-care health plans, including the ways these plans pick the physicians in their networks or panels. This week the nation’s largest group of African American physicians, the National Medical Association, swelled that chorus, charging that many managed care plans effectively discriminate against them. Dr. Walter Shervington is the group’s president.
DR. WALTER SHERVINGTON: Health plans are systematically excluding black physicians from physician panels nationwide. This omission limits patient choice in selecting physicians of like background, ultimately compromising quality health care for the patient and the community.
SUSAN DENTZER: At a news conference this week in Washington, NMA members conceded that they lacked comprehensive national data to buttress their claims. But the doctors say they have plenty of anecdotes of situations where they’ve been left out. Dr. Lenox Dingell is a general surgeon in Maryland.
DR. LENOX DINGELL: Managed care corporations loosely regulated by the state have terminated providers from their panels, often citing for business reasons, or “we have signed exclusive contracts,” which by definition are exclusionary. As a result, some of our physicians have ceased to be able to practice medicine, others forced to relocate, still others discouraged from establishing practices in our area.
SUSAN DENTZER: NMA members like San Diego Dr. Rodney Hood contend that what is driving health plans isn’t overt racism.
DR. RODNEY HOOD: I don’t think it’s a purposeful thing. I think it’s a business decision, and as usual, many business decisions don’t necessarily benefit the minority communities.
SUSAN DENTZER: For example, one reason some plans may inadvertently exclude African American doctors is their insistence that providers in their networks be certified in their specific area of practice. But although 78% of white U.S. physicians are board certified, only 69% of African American doctors are– and the percentage may be even lower for black pediatricians and others delivering primary care. In other instances, black physicians say they have apparently been excluded from health plans because they were solo practitioners and weren’t organized into the broad physician groups that plans frequently prefer to negotiate with. Dr. Gary Dennis is a neurosurgeon at Howard University in Washington.
DR. GARY DENNIS: In Kansas City, a major health plan excluded all the African American physicians. Now that happened because they were using a group practice kind of criteria, the location of certain zip codes and board certification really it is a major criteria for inclusion in plans, but these doctors were solo practitioners.
SUSAN DENTZER: In the end, the direct impact of these exclusive practices is felt by patients, the NMA charges. Doctors pointed to a study on racial and gender issues in doctor-patient relationships that was published last August in the “Journal of the American Medical Association.” The study surveyed more than 1,800 health plan patients in the Washington, DC area. It showed that African American patients felt less of a sense of partnership with their doctors than did white patients, a sense that was far more pronounced when patient and doctor weren’t of the same race. Dr. Lisa Cooper-Patrick of Johns Hopkins University was lead author of the study.
DR. LISA COOPER-PATRICK: One of the reasons this is particularly important is that, partnership or participatory decision-making, as we investigated it, has been shown in several previous studies to be correlated with patient satisfaction, as well as with improved health outcomes for several conditions, including diabetes, hypertension and emotional distress.
SUSAN DENTZER: The National Medical Association’s charges immediately set off a controversy. Dr. Charles Cutler is chief medical officer of the American Association of Health Plans, the largest HMO trade group.
DR. CHARLES CUTLER: The data that we have about the diversity of physicians in health plans is that health plans are recruiting physicians, African American and other minority physicians, to serve our membership.
SUSAN DENTZER: And in fact, says cutler, one prominent study of California physicians, published in JAMA in 1998, seems — if anything — to refute the NMA’s claims.
DR. CHARLES CUTLER: Minority physicians were as or more likely to participate in managed care than white physicians. There didn’t seem to be any barriers for minority physicians.
SUSAN DENTZER: Nonetheless, Cutler agrees, there’s at minimum a perception of discrimination on the part of black physicians that his association is eager to lay to rest.
DR. CHARLES CUTLER: We’d certainly like to talk with them about it and evaluate what is driving that perception. And we are planning to contact the National Medical Association and talk with them to see if we can’t resolve these differences.
SUSAN DENTZER: Some individual health plans stress they have made specific efforts to recruit minority physicians to serve their diverse groups of patients. But they say they can’t provide data to demonstrate their physician panels’ racial makeup because they simply don’t collect it. Still, as a result of discussions with the NMA, giant Aetna U.S. Healthcare, which counts more than half the nation’s physicians among its members, has agreed to compile information about its doctors’ racial identity; that’s in part to eliminate any concerns that discrimination exists. NMA doctors applauded these efforts, but said more remains to be done. Among other things, they want to shine a light on the relatively small proportion of African American physicians in the overall population– and on declining minority enrollments in US medical schools that could worsen the problem in the years ahead.