Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare Institute of Medicine

Do you think the average African American is better off, worse off, or just about as well off as the average white person in terms of access to health care?

Media Response to Unequal Treatment USA Today, March 22 “Racial Bias in Health Care” “In unassailable terms, the report found that even when their insurance and income are the same as those of whites, minorities often receive fewer tests and less sophisticated treatment for a panoply of ailments, including heart disease, cancer, diabetes and HIV/AIDS. By stripping away the pretense that the differences can be explained by minorities' lack of access to timely care, the report should spur doctors and patients to question why racial disparities are tolerated in medicine.”

Media Response to Unequal Treatment (cont’d) New York Times, March 22, “Subtle Racism in Medicine” “... a disturbing new study by the Institute of Medicine has concluded that even when members of minority groups have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care. Biases, prejudices and negative racial stereotypes, the panel concludes, may be misleading doctors and other health professionals.” The Washington Post, March 23, “The Health Care Gap” “Race-based inequities are a sad fact in more than one facet of American life. History has shown how hard they are to overcome. But this week's report paints a picture that cannot be ignored.”

Media Response to Unequal Treatment (cont’d) “Racist Doctors? Don't Believe the Media Hype” By Sally Satel Wall Street Journal, April 4 “Are doctors prejudiced? According to the media's coverage of a new report by the Institute of Medicine called ‘Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,’ the answer is yes... The truth is far less inflammatory than... the press would have us believe. The institute's case for prejudice in the March 20 report is weak.”

STUDY CHARGE Assess the extent of racial and ethnic differences in healthcare that are not otherwise attributable to known factors such as access to care (e.g., ability to pay or insurance coverage); Evaluate potential sources of racial and ethnic disparities in healthcare, including the role of bias, discrimination, and stereotyping at the individual (provider and patient), institutional, and health system levels; and, Provide recommendations regarding interventions to eliminate healthcare disparities.

Access (e.g., insurance status, ability to pay for healthcare) is the most important predictor of the quality of healthcare across racial and ethnic groups Access (e.g., insurance status, ability to pay for healthcare) is the most important predictor of the quality of healthcare across racial and ethnic groups It is difficult – even artificial – to separate access- related factors from social categories such as race and ethnicity It is difficult – even artificial – to separate access- related factors from social categories such as race and ethnicity The bulk of research on healthcare disparities has focused on black-white differences – more research is needed to understand disparities among other racial and ethnic minority groups The bulk of research on healthcare disparities has focused on black-white differences – more research is needed to understand disparities among other racial and ethnic minority groups Caveats – Unequal Treatment

Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Quality of Health Care Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care Populations with Equal Access to Health Care

Evidence of Racial and Ethnic Disparities in Healthcare Disparities consistently found across a wide range of disease areas and clinical services Disparities consistently found across a wide range of disease areas and clinical services Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc. Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc. Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995) Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)

Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et al., JAMA, March 13, 2002

Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993

What are potential sources of disparities in care? Health systems-level factors – financing, structure of care; cultural and linguistic barriers Health systems-level factors – financing, structure of care; cultural and linguistic barriers Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences Disparities arising from the clinical encounter Disparities arising from the clinical encounter