February 2006
The Health Disparities Myth: Diagnosing the Treatment Gap
Many experts today insist that a patient’s race profoundly affects how the medical-care system deals with him. The notion that physicians are biased against minorities--overtly or subtly--has acquired considerable weight in both academic literature and the popular press. In their new book The Health Disparities Myth: Diagnosing the Treatment Gap (AEI Press, 2006), authors Jonathan Klick, a legal scholar and health economist, and AEI scholar Sally Satel, a physician, critically assess recent research bearing on this question and discuss other factors that contribute to health-care disparities. They also suggest strategies for improving the health of all underserved Americans. They presented their findings at a February 22 AEI book forum.
Dr. Sally Satel
AEI
The notion that physician bias perpetuated the racial gap in medical care has been highly sensationalized by the media even though many of the studies cited as evidence do not actually support that claim. The Institute of Medicine’s (IOM) 2002 report Unequal Treatment claimed specifically that bias, prejudice, and discrimination on the part of physicians were significant, though not exclusive, causes of the treatment gap. This monograph’s goal is to set the record straight about the unfounded claims of physician bias and to determine what factors truly are responsible for the disparity in treatment along racial lines.
The word “myth” in the title of the monograph refers to the unproven allegation of physician bias. The race-related differences in frequency of certain types of care and quality of care are not in question.
Jonathan Klick
Florida State University College of Law
Omitted variable bias accounts for much of the methodological issues associated with the health disparities literature. The racial makeup of a neighborhood closely correlates with the quality of local health care markets, and the quality of local health care markets significantly affects a patient’s treatment. The studies on which the IOM report relies are uninterested in the residence effect and are entirely consumed by the race effect.
African-Americans and whites generally do not go to the same hospitals or see the same doctors. African-Americans are much more likely to see physicians who are not board certified and who have less access to high quality referral networks. When African-Americans and whites see the same doctors in the same hospitals in the same neighborhoods, treatments do not vary systematically. Treatment varies by race but not because of race.
Determining the primary causes of health disparities is crucial to determine appropriate solutions. If doctors’ bias is driving health disparity, cultural competence training and affirmative action in medical schools are sensible solutions. However, if the causal mechanism is poorer socioeconomic status or geographic segregation, at best the IOM prescriptions are wasteful. The real problem is that people in poorer areas get worse care. Solutions to this problem attempt to facilitate access to better care for those living in poorer neighborhoods.
The monograph addresses other issues such as focusing on health outcome differentials rather than health care treatment differentials. Defensive medicine and the consumption aspect of health care may lead to the over-treatment of white patients. Researchers need to reframe the IOM report so that policy proposals can focus on what really is driving the disparity.
Dr. Peter Bach
Memorial Sloan-Kettering Cancer Center
From a survey of practitioners we identified a group of primary care physicians and linked them to the patients for whom they submitted Medicare claims.
Our conclusions are as follows: Care for African-American and white Medicare patients is clustered among different groups of physicians. The visits for African-Americans are with physicians who are less likely to be board certified in primary specialty, less likely to be able to access needed referral services, and less likely to report being able to provide high quality care. The patterns of physician characteristics are mostly explained by the local availability of physicians where African-Americans and whites get their care.
Racial disparities in health care may emerge from differences in the quality of care that different physicians are able to provide because the differences between the physicians are correlated with the race of the patients that they see. We may not need to invoke differential treatment of patients by the same doctor to understand unequal treatment. In fact, our findings suggest that only a few physicians could substantially influence the care of both groups of patients.
African-Americans cannot necessarily find physicians with alternative characteristics locally. Therefore, interventions to improve the training and resources of physicians who treat African-Americans should be considered as an approach to reducing health care disparities. These physicians can be identified through claims, so targeting these physicians should not be as difficult a talk. Further research is needed to determine if the measures in our study are adequate surrogates for care quality.
Linda Gottfredson
University of Delaware
Although health disparities are largely attributed to differences in geography (a manifestation of wealth and social status), health scientists have noted that differences in an individual’s cognitive abilities may explain why some patients receive better care than others. This theory suggests that the variation in effective treatments may result from an inequality of reasoning capabilities among patients. Health literacy research and related studies have shown that an individual’s mental resources are essential for successfully exploiting available care.
Patients with lower general reasoning abilities are less likely to seek preventive care, to know signs and symptoms of disease, and to adhere to treatment regimens. Therefore, further investment in health care will lead to an expansion of inequality in health outcomes as a result of some individuals’ inability to take advantage of new treatments and resources. Health educators advocate that health materials be written at no higher than the fifth-grade reading level. Because this goal is unachievable for complex treatments, health care workers may find it beneficial to explain to patients more completely the procedures for effective treatment.
A high level of intelligence is useful in all aspects of life; it is essential when tasks are novel, untutored, or complex; and when situations are unclear, fluctuating, or capricious. Because individuals will interpret treatment procedures differently, identical treatment will not yield the same results. Thus, equalizing access and quality of health care does not, and can never, close the health disparity gap. Instead, health professionals must improve their patients’ understanding of the treatment procedures, and labels need to be clearer.
Christopher Foreman
University of Maryland
Claims of disparity among health conditions cast blame widely among citizens, their respective genetic endowments, medical providers, economic forces, and government policies. The claim of disparate quality of and access to health care narrows the blame considerably, often to a single factor: the biased or insensitive health care professional.
Jonathan Klick and Sally Satel’s monograph tries to determine what policies offer realistic traction against real problems. A purely racial story line may not be entirely appropriate where underlying or complicating economic, regional, or other forces are at work. The motivation for concentrating on racist health care seems to be a political reinvigoration of civil rights. Such a political strategy doubtless has its uses, but it also has limits and costs.
One striking issue in the monograph is chapter six’s implication that civil rights organizations ought to challenge the trial lawyers. Here we have the possible seeds of a new wedge issue dividing one element of the Democratic Party from another. A second issue is that Klick and Satel are not blaming the victim in their monograph. If society is to progress we absolutely must get beyond the impulse to interpret these kinds of arguments in that light.
AEI research assistant Jonathan Stricks and AEI intern James Placa prepared this summary.
