Health Care Divide
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GWEN IFILL: A new study released today finds wide discrepancies in the health care received by whites and by members of minority groups in this country. Moreover, the report prepared by the Institute of Medicine says the health care gap persists even when different racial groups have similar incomes and insurance coverage.
Some of the elements of the racial gap: Breast cancer screenings: 71 percent of white patients got them, only 63 percent of black patients did. Heart disease: For every 100 white patients who had a procedure to clear an artery, only 74 black patients did. Diabetes: black patients are over three-and-a-half times more likely to have a limb amputated.
Two members of the report join us now to discuss the panel’s findings and recommendations. Dr. Risa Lavizzo-Mourey is senior vice president of the Robert Wood Johnson Foundation, and Dr. Joseph Betancourt is a senior scientist in the Institute for Health Policy at Harvard Medical School.
DR. JOSEPH BETANCOURT: Thank you.
DR. RISA LAVIZZO-MOUREY: Thank you.
GWEN IFILL: How did you reach your conclusions? What were the methodologies for this?
DR. RISA LAVIZZO-MOUREY: We had a 15-member committee that reviewed literally dozens and dozens of articles that have been published in the scientific literature. We also conducted workshops, brought the public in and conducted focus groups to really try to understand the way patients were perceiving the health care system. And we combined all of that, synthesized that information to come up with our findings and recommendations.
GWEN IFILL: It raises so many questions, but I guess I’ll start with access to care. Was this a question that minority patients had less access to care?
DR. JOSEPH BETANCOURT: No. You know interestingly enough, our charge from Congress as part of the Institute of Medicine in conducting this study was in fact to look once access has been achieved. So clearly there’s many factors that contribute to disparities in health outcomes, such as poverty and social determinants, and not having access to health care. But the charge to us as a committee was to look at patients within the health care system. Once you have access to care, are there disparities in both diagnostic and treatment procedures and in outcomes within the health care system?
GWEN IFILL: Dr. Lavizzo-Mourey, was this – because of the charge that Congress gave you on this report, did you decide in advance that these discrepancies were driven by race or is this something you discovered as you went along?
DR. RISA LAVIZZO-MOUREY: We looked at the evidence very carefully. And we came into it with an open mind. I think there were — with 15 people on a committee, there were obviously very different views about whether the evidence was going to come out positive or negative. But I think it’s fair to say that after a very few meetings and looking at the weight of the evidence, as I said, dozens and dozens of studies, the committee was in full agreement that this was a big problem.
GWEN IFILL: Why — for those of us who are lay people in this — why isn’t this a matter of socio-economics instead of race, instead of people who are of color, have less access or don’t make as much money that they’re likely to get less care?
DR. RISA LAVIZZO-MOUREY: Well, once you get into the doctor’s office or into the health care system, I think we all want to believe that medical care should be blind, that race should not be a factor. But, in fact, as we have looked at the studies, one of the things that’s pretty clear is that we live in an environment where we all bring some baggage to that encounter, if you will. We have stereotypes.
And let’s say because of living in this country one has a stereotype that African Americans are less intelligent, in the heat of an encounter, which has all kinds of constraints of time and perhaps not fully understanding what one is saying to other, the doctor speaking in jargon for example what can sometimes happen is those stereotypes start to play out on both sides. And that can very much exacerbate these discrepancies.
DR. JOSEPH BETANCOURT: Yeah. And, in fact, we don’t deny that socio-economic factors play a role here. It would be naive to say that they don’t. But we really focused our literature review on studies in which as much of these outside factors were controlled for. Socioeconomic status in its totality is different to control for in all instances. But, again, we had a preponderance of evidence, which highlighted the fact that despite access or despite socioeconomic factors, there still seemed to be significant differences in treatment.
GWEN IFILL: Now when we talk about these kinds of areas, are we talking black/white, or are we talking other races as well?
DR. JOSEPH BETANCOURT: Well, I think that the interesting part about our work and one of our major findings was that the majority of literature in the area of health disparities focuses on African-American and white differences. In fact, that stems from the historical context in which we have collected data on race and ethnicity almost before 1970 looked at just white, black and other. So our most robust data and the most robust studies are comparing African-Americans and whites.
That being said, we do have a fair amount of growing literature that highlights disparities in Hispanic populations, Native American populations, and Asian and Pacific Islander populations as well. I mean, we feel that this is in some ways the tip of iceberg and we need to learn more about what is going on in these other communities.
GWEN IFILL: Are there certain diseases which are more likely to go un- or under diagnosed because of these kinds of disparities?
DR. RISA LAVIZZO-MOUREY: There are clearly areas where we have more information that there are problems but almost wherever you look, there are problems. Some of areas that the literature points to are cardiovascular disease — we know and, as you cited, some of the statistics that African-Americans and other people of color often don’t get the kind of technological advanced treatment that would be useful in prolonging life and making them more healthy. Cancer studies show similar findings.
We know that in the area of kidney disease, African-American and other people of color are less likely to get transplants. There’s frequently less pain medicine given. So it is pervasive. And there’s data in almost every place you look, but the areas where it really shows up are in cardiovascular disease and cancer. I think those are the areas that the data is most robust.
GWEN IFILL: Is the outcome different in this data if the care givers are themselves minorities?
DR. JOSEPH BETANCOURT: There’s not a whole lot of literature that let’s us know that. In fact, if we look at our health care work force right now, if we look at physicians, only about 6 to 8 percent of all our physicians are minorities. As a result, we’re making certain assumptions about the variety of physicians and who is providing care just by those numbers. The majority of physicians are, in fact, white.
The there are some studies that highlight the fact that when an African-American physician, for example, is with an African-American patient, the patient senses that their encounter, their visit with that doctor is more participatory. And what I mean by that is that they are able to weigh in with their opinions and give their perspectives.
So I think we didn’t — we were unable – again due to the literature — to dig down deep and look if these differences are related to race concordance or discordance between provider and patient. But in fact, there are some studies to show that minority patients may be more satisfied with minority providers.
DR. RISA LAVIZZO-MOUREY: If I could just add to that –
GWEN IFILL: Sure.
DR. RISA LAVIZZO-MOUREY: I think one of the things that in terms of a concrete study that has been done looking at the amount of time various racial groups spend with other racial groups, white physicians spend more time with white patients than they do with African-American and other minority patients. In that same study that I’m talking about if you look at the amount of time spent by African-American doctors with African-American patients, it was longer than the white doctors spent with African-American patients. So there seems to be some more quantitative evidence.
GWEN IFILL: And a lot of people will look at what you just said and your earlier comments about stereotypes being rampant and say it’s racism. This is America — of course this would happen. Is that true? Is it racism? Or is unknowing behavior?
DR. JOSEPH BETANCOURT: Our report did not find any direct evidence of racism. In fact, we hope as health care providers that in fact many health care professionals enter the profession with the ideals of professionalism and equity and ideals that in fact would make them well-intentioned to care for patients. We think that physicians and patients really want the same thing – the best health outcomes. And in fact we’re talking about stereotyping — we’re talking about physicians being susceptible to what we all are susceptible to. Stereotyping is a normal cognitive process. It allows us to take complex information and distill it down when we have to make quick decisions.
The medical encounter is characterized by three factors: Being rushed or having a short amount of time, having to multitask and being stressed because these are high pressure situations. All those three factors contribute and activate stereotypes even among the very well-intentioned. So, in fact, many physicians may not even know that they may be treating these patients differently.
GWEN IFILL: So what are the remedies that you recommend? Is there a way around this?
DR. RISA LAVIZZO-MOUREY: Well, we believe there is. There’s a comprehensive set of recommendations that we’ve laid out. I’ll just highlight a few. I think one of the most important things is to increase the awareness about this issue. Many people believe that it’s not an issue or that it’s due only to access. And I think one of the important things is to raise awareness. Secondly, we have talked about the difference in the quality of the encounter when the patient and the provider have the same background. And I think that points to the need to increase the number of minority health care providers in our system. Six percent in no way reflects the population, and certainly does not reflect the population of the future.
GWEN IFILL: What is the first thing that can happen of these recommendations, Dr. Betancourt?
DR. JOSEPH BETANCOURT: One area that there’s something going on right now – in fact, two areas – one area is in the area of education. So the LCME, which accredits medical schools, is already looking at standards that would encourage medical schools to teach both how we make decisions and racial and ethnic disparities, so people get increased awareness, but also tools and skills to better understand and manage patients from different backgrounds. That’s already underway and we have great hope that that will help us along in this process.
GWEN IFILL: Dr. Risa Lavizzo-Mourey and Dr. Joseph Betancourt. Thank you very much for joining us.