Addressing Disparities in Health and Health Care: Issues for Reform

Dear Chairman Stark, Representative Camp and members of the Committee. My name is Sally Satel. I am a resident scholar at the American Enterprise Institute, lecturer at Yale University School of Medicine, and the staff psychiatrist at the Oasis Drug Treatment Clinic in Northeast Washington D.C.

Thank you for the invitation to present my views on racial and ethnic minority health status and the key principles upon which remedies should be based.

Let me begin by noting that a number of realities are well-established.

Enhancing access to care and quality of care, though essential steps toward improving health status among racial and ethnic minorities must be vigorously fortified by other improvements that will enable patients to benefit the most from the care they do receive.

First, we know that differences in health status exist between various ethnic and racial groups, and that there are often discrepancies in indicated procedure rates across groups.

Second, we know that many of the factors linked to these discrepant rates (e.g., access to care, geographical differences, good quality care) are much more closely tied to socioeconomic (status), than to race per se.

Third, and most relevant to my comments today, we know that these factors do not account for the full extent of discrepancy between groups.

Thus, enhancing access to care and quality of care, though essential steps toward improving health status among racial and ethnic minorities must be vigorously fortified by other improvements that will enable patients to benefit the most from the care they do receive (and to need it less frequently and less intensively).

My remarks today will focus on those additional areas of need. To effect these changes, health care systems and programs must have flexibility to target local needs in creative ways.

Correlates of Health Differentials

Geography: Geographic residence often explains race-related differences in treatment better than even income or education. Because health care varies a great deal depending on where people live, and because blacks are overrepresented in regions of the United States that are burdened with poorer health facilities, disparities are destined to be, at least in part, a function of residence. Researchers who fail to control for location effects of low-income will misdiagnose the underlying causes of many racial disparities in health.

Hospital Quality: An underlying cause of disparities may be that minority patients are more likely to receive care in lower-performing hospitals. Hospitals that treat greater numbers of minority patients generally offer poorer quality service than those that treat fewer minorities. Conversely, within hospitals, the quality of care is generally comparable between whites and minorities when they are admitted for the same reason or receive the same hospital procedure.

Quality of Physician: National physician survey data indicate that physicians in high-minority practices depend more on low-paying Medicaid, receive lower private insurance reimbursements, and have lower incomes. These constrained resources help explain the greater quality-related difficulties delivering care--such as coordination of care, ability to spend adequate time with patients during office visits, and obtaining specialty care--that relate directly to physicians'ability to function as their patients'medical home.

Beyond Access and Quality: Beyond the obvious need to expand access and enhance quality of care, other factors demand attention if health differentials are to be narrowed.

Establish continuity of care with same provider: Patients who see the same doctor from visit to visit have the opportunity to establish a rapport with him (which, in turn, will lead to better adherence with treatment regiment and conscientiousness about self-care). Yet African Americans are more likely than whites to rely on emergency room care because they do not have a primary care physician. Other venues of non-continuous care are community clinics and hospitals. (Note that having Medicaid does not necessarily correlate with having a regular source of care.)

The Commonwealth Fund 2006 Health Care Quality Survey finds that when adults have health insurance coverage and a medical home--defined as a health care setting that provides patients with timely, well-organized care, and enhanced access to providers--racial and ethnic disparities in access and quality are reduced or even eliminated.

Expand the average length of the doctor visit: One of the most effective ways to enhance the doctor-patient relationship is for doctors to spend sufficient time with each patient--more than the standard fifteen minutes--to elicit patients' concerns, needs, values, and preferences. We need to have Medicare codes expanded to pay for cognitive, evaluative services--and pay more for them.

Foster health literacy: A patient's accurate understanding of the nature of his illness and the purpose of various therapies is essential to self-care and treatment adherence. An important new study from an economist at Columbia University documented that differences in patient self-management trigger a racial mortality gap even when access and treatment for chronic heart failure are equalized. The authors estimate that targeting compliance patterns could reduce the black-white mortality gap by at least two-thirds. But compliance is difficult. Sociologist Linda Gottfredson puts it well when she says that "chronic diseases are like jobs." She focuses on diabetes but her list of tasks that patients have to perform to control and monitor their conditions can be generalized to other chronic conditions such as moderate to serious asthma, hypertension, renal failure, and chronic heart failure.

Set of duties to perform:

  • Requires training
  • Implement appropriate regimen
  • Continuously monitor physical signs
  • Diagnose problems in timely manner
  • Adjust food, exercise, meds in timely and appropriate manner
  • Coordinate & communicate with others
  • Exercise independent judgment with only occasional supervision from medical personnel.
  • Efforts to control the condition are often tiring, frustrating, and affects family life

Most Type 2 diabetics find it hard to believe they are truly sick until it is too late to avoid the complications (pain, dysfunctional eyesight, infections, etc). This is why following disease prevention strategies is even more challenging for those with overwhelming personal and family and occupational problems. Health recedes into the background, surpassed by more pressing daily realities and stresses.

Common Sense Local Innovations

  • Educational modules that prepare and coach patients to ask questions and present information about themselves to their doctors are promising where implemented.
  • Grassroots outreach through black churches, social clubs, and worksites
  • Patient "navigators" to help negotiate the system
  • Language services
  • Bonuses/incentives to get more good doctors into distressed neighborhoods.
  • Clinic night hours: a great boon to patients with hourly-wage employment who risk a loss of income, or even their jobs, by taking time off from work for doctors' appointments.
  • Active pharmacists who issue reminders, provide education to ensure patients grasp what they need to know; hotlines

A key element here is that these services need to be reimbursed.

Conclusion

Resolving health differentials between racial and ethnic groups depends on improved access to care and quality of care. However, reform in those areas alone will not be sufficient. Individuals need to be able to exploit the care that is available to them. And the way to help them achieve this is to target problems that stem from habits and dispositions associated with life lived on the lower reaches of the socioeconomic ladder. To tailor interventions most effectively, healthcare systems need to have the flexibility to respond to specific needs of individual communities.

Sally Satel, M.D., is a resident scholar at AEI.

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