Healthcare Disparities, Denial, and Solutions

Racial and ethnic healthcare disparities are differences in care or outcomes of minority patients that have nothing to do with the patients’ underlying medical conditions. They can result from poor access and quality to language barriers and discrimination.

Unfortunately, healthcare disparities in the US are all too common. Although the quality of healthcare in the US is poor

for many Americans, numerous studies have shown that racial and ethnic minority populations experience generally poorer outcomes than the population as a whole.

These groups are likely to receive a lower quality of treatment than their white counterparts—even when health coverage, income levels, and other social and economic factors are equal. National healthcare disparities have been extensively documented in heart disease, diabetes, depression, and other conditions.

• Patients who were appropriate candidates for coronary angiography have found race differences in obtaining a referral for this diagnostic procedure (African American 58.7%, White 82.4%).

• A lower percent of minority patients were recommended for coronary revascularization than white patients in the VA health system, where there are no differences in the ability to pay and providers are paid a salary.

• Also in the VA health system, African Americans were less likely than whites to have LDL checked in the past two years and have a dilated eye exam—both standards for proper diabetes care.

• Among Medicare patients who had a myocardial infarction, African American patients are less likely than white patients to receive beta blockers, the established standard of care.

• African Americans are also less likely than whites to receive follow-up care after a mental health-related hospitalization.

Although the existence and causes of health disparities are well known, they still persist. There are several reasons for their prevalence, including denial on the parts of various decision-makers and other actors in all levels of healthcare regarding the pervasiveness and extent of health disparities, and the lack of real-world, practical solutions.

Denial Fuels the Problem

You see it all the time. A patient comes in—smokes too much, eats too much, exercises too little, and can’t seem to figure out why he doesn’t feel well. It couldn’t possibly have anything to do with his behaviors and lifestyle choices. It must be caused by something beyond his control, like genetics or the environment.

Denial—it happens to the best of us. Despite overwhelming evidence that a problem exists, we choose to pretend it’s not there. And often, even when the problem is acknowledged, we try to minimize its seriousness. The same kind of denial can, and often does, occur within a health organization or practice when it comes to health disparities. Even worse is when a doctor or administrator acknowledges that racial and ethnic disparities exist, just not in their office, hospital, or clinic. Basically, it’s someone else’s problem, not theirs.

Speaking to this point, Dr. Thomas Sequist, a primary care physician at Brigham and Women’s Hospital in Boston, remarked during a presentation at the Academy Health Annual Research Meeting in early June that “providers are a crucial pivot point; if they don’t think it’s an issue, we will have limited success with interventions.”

The leaders of healthcare organizations aren’t the only ones in denial. Most of the public is too, apparently. According to a 2005 report by the Robert Wood Johnson Foundationand Harvard University, only 32% of Americans think that it is more difficult for minorities to receive quality healthcare than it is for white Americans. Fortunately, the movement to eliminate racial and ethnic health disparities is growing. Since the release of the 2002 Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, stakeholders from policymakers to patients are taking notice of the scope of the problem. Beyond acknowledging that healthcare disparities exist and have a measurable detrimental effect on health outcomes for a large portion of our population, what concrete and practical steps can healthcare providers and organizations take to reduce these disparities when funds are already tight?

First and most importantly—if you don’t already—collect race and ethnicity data from your patients. Many providers, convinced that healthcare disparities did not exist in their own organizations, have been surprised when the data they collect reveal a different reality. In this way, settings and practice areas where racial and ethnic disparities are most prevalent can be identified, and baseline measures can be taken to assess future improvement. At the same time, areas in which health outcomes

for minority and majority patients are equal can be encouraged and studied in order to provide insight into best practices that can help drive change. Certainly, developing monitoring efforts will face some challenges, including the need to ensure patient privacy and prevent inconsistent use and understanding of the terms “race” and “ethnicity.” However, the benefits of collecting this information outweigh the costs.

Patients already fill out numerous forms and paperwork detailing personal information, and most are comfortable identifying their heritage. Secondly, when racial and ethnic disparities are identified, take action. Using scarce resources to address health

disparities through interventions, incentives, and policy changes may sound like an unfunded mandate, and there are other pressing issues on a physician’s endless list of things to do. But in the long run, it costs less to take active measures to reduce healthcare disparities in your office or organization than it does to ignore them.

Denial among doctors and other healthcare leaders that these disparities occur at their own organizations is a barrier that will have to be overcome. When the causes of health disparities inevitably include poor clinical and cultural competence, profit-enhancing policies, and discrimination, it’s difficult to take responsibility. But, doing the right thing will improve care, outcomes, and trust among all patients. It will ensure high-quality healthcare for all.

Funding Fuels the Solution

A growing number of healthcare organizations are testing strategies to improve the quality of care they deliver to minority patients. In an effort to advance the discussion about reducing racial and ethnic disparities in healthcare from theory to practice, healthcare stakeholders need tested, cost-effective strategies that can produce real improvements in the quality of care delivered to minority patients.

The Robert Wood Johnson Foundationis investing millions of dollars to evaluate approaches and disseminate solutions to eliminating racial and ethnic disparities in healthcare. Through the Finding Answers: Disparities Research for Change initiative, researchers at the University of Chicago will award and manage approximately $6 million in research grants to provider organizations that are implementing interventions. Grant awards through this initiative are used to evaluate the interventions to understand what works and—just as importantly—what doesn’t work to improve healthcare for minority patients. These funds will motivate health plans, hospitals, and community clinics to place eliminating racial and ethnic disparities at the top of their quality improvement agenda.

“We know disparities exist and these differences in care by race and ethnicity are unacceptable,” says Dr. Marshall Chin, director of Finding Answers. “There is a clear need for solutions that can improve the health of millions of Americans.” The Finding Answers team will focus on areas in which evidence of racial and ethnic disparities is strong and the recommended standard of care is clear. During the first of three rounds, the program received 178 proposals and was pleased to fund 11 interventions around the country. Grants ranged from $50,000 to $300,000 for up to two years. The second round of grantees will be announced in May 2008, with a third call expected shortly thereafter. “As the process evolves we learn more about promising strategies and areas that still need to investigated,” says Scott Cook, PhD, deputy director of the program. As a result, the requests for proposals become more specific and the competition becomes stiffer.

Cook adds, “We’re looking for projects that are original, innovative, and involve multiple partner organizations.” In addition to discovering and evaluating interventions to reduce racial and ethnic healthcare disparities, Finding Answers has also conducted a systematic review of existing literature that will be published this fall as a supplement in Medical Care Research and Review.

Once grantees complete the evaluation of their interventions, Finding Answers and the Robert Wood Johnson Foundation will disseminate the findings nationally and help organizations translate them into real-world practice.

For more information about Finding Answers: Disparities Research for Change or to receive the third call for proposals, contact the National Program Office tollfree at (866) 344-9800 or info@solvingdisparities.org. To learn more about the Robert Wood Johnson Foundation’s commitment to solving racial and ethnic disparities in healthcare, visit www.rwjf.org.

Nicole M. Keesecker is a Health Communications Specialist with Finding Answers: Disparities Research for Change, a program launched by the Robert Wood Johnson Foundation to award and manage research grants to healthcare organizations implementing interventions aimed at reducing disparities. Visit www.solvingdisparities.org to learn more about the missionand goals of this organization.