Unequal Medical Treatment
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TERENCE SMITH: The quality of health care in the U.S. depends in part on the color of the patient’s skin. Today’s New England Journal of Medicine published three studies showing a substantial gap remains between health care that blacks receive compared to whites. The studies found that there have been marginal improvements since the 1990s. The gap narrowed when it came to better access for less expensive treatments like mammograms, diabetes testing, and heart drugs. But there were still disparities for more expensive treatments like heart and back surgery or joint replacements.
For more on these findings and their larger context, I’m joined by Dr. Ashish Jha of the Harvard School of Public Health and the author of one of the studies in the New England Journal and by Dr. David Satcher, former U.S. Surgeon General, and now interim president of the Morehouse School of medicine in Atlanta. Welcome to you both.
Dr. Jha, let me begin with you say, taking these three studies together, what is the central message that it conveys to you about the disparities in health care in this country?
DR. ASHISH JHA: Sure. Well you know, we have known for over 20 years that blacks and whites receive very different health care within our health care system. And in the late ’80s, early ’90s there were substantial efforts both by the federal government as well as by state governments to try to reduce these disparities. And when you take these three studies together and take a step back, what you see is that the gaps in care between whites and blacks persist, in many areas they’re getting worse in a few small areas we see glimmers of hope, but overall blacks and whites continue to receive very different health care in this country.
TERENCE SMITH: And these studies, Dr. Jha, were comparing blacks and whites who have essentially the same access to insurance and coverage and health care?
DR. ASHISH JHA: Absolutely. So the differences here were not about access to doctors or access through health insurance. The study that I led looked at people who had Medicare fee-for-service program; it was elders who all had Medicare. The other studies also looked at patients who had access to health care.
TERENCE SMITH: Dr. Satcher, this is a problem I know that you have worked on for years and have spoken out about, when you see these studies, what’s your reaction?
DR. DAVID SATCHER: Well, my reaction is one of great disappointment because the health care system, which should be a major part of the solution to health disparities in this country, is still a major part of the problem. It’s not the only problem, but it’s the major part of the problem. In fact in Healthy People 2010, the nation’s health plan for this decade, one of the goals was the elimination of disparities in health.
And that was the first time goal was elimination; we thought it was very important to make that commitment to work toward elimination of disparities in health. So we have a lot of work to do. But we do know from some of these studies and others that it’s not hopeless; that it is possible by measuring the quality of care and requiring reporting to improve performance. It is possible by training or in some situations, to improve performance.
So while we have not yet solved the problem, we shouldn’t give the impression that it’s hopeless, we should redouble our efforts and as Dr. Jha says in his article, this is a major call to action.
JEFFREY BROWN: Dr. Jha, when you look at the different cases, give us some examples in a clinical situation where this disparity might exist.
DR. ASHISH JHA: Sure. I’ll use an example from one of the studies that accompanied mine. When a patient comes into the hospital with a heart attack, we know from that study as well as countless other studies that have looked at this topic that black patients, for example, are much less likely to get heart bypass surgery.
And, you know, this is a surgery that President Clinton had; this is obviously a very common, well-known surgery. It has a profound impact when used correctly on people’s lives, their well being. And we know from these studies that black men are much less likely to get it than white men. And black women are much less likely to receive these surgeries compared to white women.
TERENCE SMITH: Dr. Satcher, why would that be the case, why that difference?
DR. DAVID SATCHER: Well, I think the study by the Institute of Medicine, the report by the Institute of Medicine in 2002 looked very comprehensively at a lot of different studies. And while we still don’t fully understand the answer to your question, they sort of decided that there were three areas that we should really be concerned about.
And of course one of those areas is just the area of bias and discrimination; it is a part of our history, a part of our lives. And while it’s very unfortunate to find that it affects the health care profession also, we do know that this is one of the areas of concern.
Another area of course is just the health care system itself, and from a standpoint of legal and regulatory issues, there are problems that can be solved. And that was demonstrated by the Office of Civil Rights during the Clinton administration that we can make changes in the system that can improve health care and reduce disparities.
And finally there’s an area which we refer to as patients’ preference. There’s a question as to whether or not in some cases some patients may demand more care than others. And that might relate to several things in terms of patients’ histories and backgrounds.
So we have some areas that we should be working on and we are working on the issue of culture competence, for example, as America becomes increasingly more diverse, we ought to be looking at that. We have much more data on blacks and whites than on other groups. But we should look very critically at differences in culture, and how they affect patient care. And medical schools should redouble their efforts in their training of medical students and physicians to eliminate those problems.
TERENCE SMITH: Dr. Satcher, staying with your very first point there you said there is a certain bias that exists even in the providing of health care. Explain what you mean by that. Are you saying that a doctor is going to react differently to two patients, one white, one black, when confronted with a similar medical situation?
DR. DAVID SATCHER: Yeah, in fact there were studies discussed in the Institute of Medicine report where there was very good evidence the fact that white patients and black patients were looked at differently by some white physicians, when compared to others.
So it has been clearly documented that there are differences in the way physicians respond to patients based on race in many cases. It is a difference that we see in other parts of our society; it is most disappointing when you see it in medicine. It is most unacceptable, and I think we should make that point very clear that it’s unacceptable.
But clearly there is prejudgment, for example, of patients. A black patient coming into emergency rooms with sickle cell crisis were often thought to be just trying to get drugs. And that judgment was made in some cases so there are studies showing that there are differences in the way patients are viewed and that patients are often prejudged based on their color.
JEFFREY BROWN: Dr. Jha, did you find evidence of some of these things either of bias or a difference in the demands for services that Dr. Satcher referred to? Did you find some evidence of these things?
DR. DAVID SATCHER: You know, neither our study nor the other two studies that accompanied ours looked specifically at that question. But I just want to take one step back and say something, which is, you know, as a practicing clinician, I like to believe that I take care of everyone – whites, blacks, Latinos, really everyone — the same. But the reality is that at the end of the day blacks and whites are getting very different care and whether it’s me or other physicians who are treating patients differently or there are other aspects of the health care system that are treating patients differently, let me echo what Dr. Satcher said, which is at the end of the day these differences are not acceptable.
We’re not talking about small differences; we’re talking about substantial differences between the care that whites and blacks receive, differences that have a very profound impact on whether people live or die, what quality of life they have. And that in the year 2005 really should not be something we should be willing to live with.
TERENCE SMITH: Well, let me ask you both very briefly, what can be done about this? If this has been a persistent problem, it’s been studied for years, you said over 20 years Dr. Jha, what can and should be done about it? Dr. Jha first.
DR. ASHISH JHA: Sure. You know, because it’s a complex problem, it’s clearly going to require a multi-faceted solution. So what is that going to entail? Well, first we’re clearly going to have to do a much better job of education. And Dr. Satcher has already alluded to some of these things but let me try to be a little bit more specific.
You know, I think too many doctors still are not aware of the fact that we treat whites and blacks differently in our health care system. So there has to be a concerted effort to do a much better job of educating physicians about the quality of care they provide.
And then I think, you know, on a state level, there are 34 that have set up offices of minority health; many have not been funded adequately so I think state government, the federal government, all of the different sort of stakeholders of health care are going to have to look at this issue and really take this on as a major challenge so that we can hit the 2010, the 2010 goal of eliminating disparities. It’s going to be hard work but I believe we can get there if we really make brand new efforts.
TERENCE SMITH: All right, Dr. Satcher, what would you add to that list of things that can and should be done?
DR. DAVID SATCHER: Well first I would agree — let me just reiterate again that health care is only one of the factors in disparities in health. We should not forget that access is still a problem even though it was controlled for in these studies. By the same token environmental differences are problems of terms of disparities in health.
But in talking about health care I think it has been demonstrated that you can make a difference in the quality of care through education/training of physicians, through requiring reporting of — as we used to say we like to say, what gets measured gets done, so it’s very important that health plans measure the quality of care that their patients receive on the basis of race.
Let’s point out that there was one of these studies in the New England Journal of Medicine today where HEDIS measures were looked at in Medicare plans that were managed care plans. And in this case seven of the nine HEDIS measures actually improved during this period of time from 1997 to 2003.
So we have to think that there was something happening in these managed care plans that resulted in this improvement. Even though it did not eliminate disparities, it certainly reduced them.
TERENCE SMITH: Okay, Dr. Satcher and Jha, thank you both very much.
DR. DAVID SATCHER: Thank you, delighted to be here.