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2004-08-20

Study Shows Racial Disparity in Healthcare

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A new study finds that doctors who treat African American patients are less likely to be board certified and less able to refer patients to specialists than doctors who treat white patients. We speak with the author of the study as well as a doctor representing African American physicians. [includes rush transcript]

Doctors who treat African American patients are less likely to be board certified and less able to refer patients to specialists than doctors who treat white patients. This according to a study published on August 5th in the New England Journal of Medicine, entitled "Primary Care Physicians Who Treat Blacks and Whites."

The study used Medicare data from a survey of doctors who treat patients 65-years and older. It found that geography may be a factor because physicians in largely Black neighborhoods say they have trouble providing high quality care.

  • Dr. Peter Bach, Lead author of the study "Primary Care Physicians Who Treat Blacks and Whites" published this month in the New England Journal of Medicine and a pulmonologist/intensivist at the Memorial Sloan Kettering Cancer Center with expertise in quality of care and epidemiologic research methods.
  • Dr. Winston Price, President of the National Medical Association, representing African American physicians.

Transcript

This is a rush transcript. Copy may not be in its final form.

JUAN GONZALEZ: We’re joined now by the lead author of the study, Dr. Peter Bach, who is a pulmonologist and internal medicine doctor at the Memorial Sloan Kettering Cancer Center with expertise in quality of care and epidemiological research methods. Welcome to Democracy Now!

DR. PETER BACH: Thank you for having me.

JUAN GONZALEZ: Could you tell us a little bit about the study and what you found?

DR. PETER BACH: You have done a good summary. The purpose of the study was to determine first whether or not Black and white Medicare patients were going to the same doctors, or if, rather, Black and white patients mostly went to different doctors. And if the second situation was present, then the question was whether or not the doctors that Blacks went relative to the ones that doctors that whites went to could provide the same quality of care. As you mentioned, the study was based on a survey of physicians. And in that survey, the doctors were asked, are you able to provide certain things for your patients, including access it specialists, access to imaging tests or radiology tests like C.A.T. scans and M.R.I.'s, access to what's referred to as elective admissions at the hospital where a doctor would bring a patient into the hospital to figure out what is going on with him, even though it’s not an emergency. And other thing like that. And what we found was first of all, Black and white patients really don’t go to the same doctors. Most of the care provided to Black patients is provided by a very small number of primary care physicians. About 20% of all U.S. primary care physicians provide about 80% of the care to Black patients, while most of the care for white patients occurs with other physicians. Then we observed that of the physicians treating Blacks and whites, there were differences, not only as you mentioned in the physician’s rate of board certification, physicians treating Black Americans are less likely to be board certify than those treating white, but also that the physicians treating Blacks were more likely to say they could not provide access to particular resources for their patients. Now, the reason we pursued this study was we’re trying to understand why it is that for essentially all diseases, Blacks in the United States are diagnosed later or in other words, the diseases are more advanced and harder to treat, and also after their diagnosed with diseases, they receive less good treatment and have worse outcomes. Our hypothesis was that one of the things happening is that when a Black patient has, let’s say, a non-specific symptom or sign, they feel sick, put simply, and go to the doctor, they’re more likely to see a doctor who either doesn’t have the resources or doesn’t have access to the tests or the admissions to hospitals or other sorts of things that are needed to rapidly and thoroughly evaluate what is causing that patient not it feel well. And when what is going on there is something serious, heart disease or cancer, there is delay for Black patients relative to whites, where whites are more likely to go to physicians who do have access to those resources.

JUAN GONZALEZ: Now, why would that be? If your study is based largely on Medicare data, and Medicare is universal, obviously, for people over 65, then would this be that the white patients tend to have additional insurance that provides greater opportunities for more doctors to service them, or, have you been able to analyze why you think this is happening?

DR. PETER BACH: We can’t tell from the study exactly why it is that physicians are telling us they face these obstacles, and remember that in the survey, we asked the physicians about all of their patients, not just their Medicare patients, but only studied their Medicare patients. Because we had high quality data on where those patients go and where they receive their care. But the issue of why the physicians cannot access or face obstacles to accessing these resources is probably quite a bit more complicated than the patients’ insurance alone. There has to be the availability — local availability of these facilities. If the patient has an insurance card, but there is no radiology facility nearby, that insurance card doesn’t do them that much good. Similarly, if there are not a lot of high quality specialists in the area, or if those high quality specialists are overworked, it can be equally hard for those physicians to obtain access to those specialists for their patients in those communities, even though the patients have insurance.

JUAN GONZALEZ: Well, we’re also joined on the phone by Dr. Winston Price, who is the president of the National Medical Association, which represents African American physicians around the country. Welcome to Democracy Now!

DR. WINSTON PRICE: Good morning.

JUAN GONZALEZ: Dr. Price, your reaction to the study by Dr. Peter Bach and the disparities in medical treatment to African Americans?

DR. WINSTON PRICE: Well, let me preface my comments by thanking Dr. Bach for bringing these things to the surface, but caution the conclusions in the study as Dr. Bach clearly pointed out, there are much more complex issues that need to be gleaned from why there are disparities in the health care outcomes. That said, I think it’s important to recognize that the study pointed out that a minority of physicians are taking care of the majority of Medicare patients, but if you think of the analogy of firemen running into a burning building, these minority of physicians are carrying their stethoscopes and whatever intellectual resources they have to put out fires of disease. They are the troopers who are going into these communities where there are patients of need. It’s the system’s responsibility to make sure the water is turned on. Otherwise, they cannot provide the quality of care that’s necessary for these complex patients. The communities where the study points out that the physicians are having difficulties taking care of these patients are the communities where safety net hospitals and lack of specialists are paramount, and the more complex the patient, the more chronic their disease, the more it’s necessary to have the backup facilities, the radiology centers, the pharmacies with adequate stocks of medications to support the complex polymorphic disease that these individuals have. And those systems are just not in place in those communities. It’s not surprising to me that these were the results of this particular survey. We already know from the Institute of Medicine report that was presented more than two years ago that the quality of care provided to minorities across the country are not to the same level of care that are provided to white patients. And this is the cause of a complex issue of racism in medicine as well as issues with respect to access and availability. And that needs to change if we’re going to see a change in the outcome.

JUAN GONZALEZ: Well, what about this issue of access and availability in terms of the backup systems, the testing systems, the hospitals and so forth to Black and white patients. I would assume that since most hospitals these days need patients to fill their beds that even those institutions that historically have not reached out to service Black or minority communities who want to do that these days, but yet there still is apparently an enormous problem in terms of access. I’d like to ask Dr. Bach first and Dr. Price on that issue.

DR. PETER BACH: I think it’s not clear, certainly from our study, to what extent the obstacles that the physicians face in referring their patients are directly a result of let’s say, not enough hospital beds in the neighborhoods, as opposed to other sorts of obstacles they may face. It’s difficult — it’s an ordeal it get admitting privileges, for example, for a doctor practicing in the community, to get admitting privileges to a particular hospital. Each set of admitting privileges to each hospital requires additional work and maintenance, and it’s not always a guarantee. It’s possible that in communities, even if there are just as many hospital beds, if there are smaller hospitals or ones where it is harder to get admitting privileges that these physicians may face additional obstacles that the physicians treating white patients are not facing. So it, may be more — it may be more complicated than simply a number of hospital beds in the neighborhood or something like that.

JUAN GONZALEZ: Dr. Price, what about this issue of admitting privileges. Your members, African American doctors tell you that they have more difficulty getting admitting privileges to major hospitals?

DR. WINSTON PRICE: Well, I mean, those are two separate issues. I think across the board, the bias that is experienced by African American and Latino physicians is paramount, is well documented, and is part of the problem with respect to the disparities that we see in the numbers, and the diversity within the health care system. That said, I think one of the — one of the things that I did not see in this particular study is it gave a sense of the level of frustration that the physicians taking care of these Medicare patients, both Black and white physicians, the frustration they have in trying to deliver care and in trying to get the patients admitted, but the study did not detail — the data may be there — but it did not detail the degree to which these physicians attempted to admit patients. And so, what would be important as well is not only a level of frustration, but a documentation of an attempt by one of these physicians to admit a patient, and contrast that to a white physician treating a patient with similarly complex disease with a similar presentation at the same time under the same circumstances. In the J.A.M.A. article, looking at cardiac disease, it was pointed out in that study that Black females seeking advanced cardiac diagnostic studies with equal access and equal levels of insurance got differential care. And so it speaks a level of racism within health care.

JUAN GONZALEZ: Doctor Winston, let me ask you, the federal government has set a goal by 2010 eliminating racial disparities in health care. Your association has some recommendations in terms of what might be able to be done to provide equal access and equal care?

DR. WINSTON PRICE: Well, with respect to this particular study, I think what was pointed out and what our recommendations are is that there needs to be greater attention given to improving the access to quality health care for Black patients. The circumstances under which physicians serving Black Medicare patients are stressful. We know that. They usually are paid less. They usually have to work longer hours, and they usually have limited resources in terms of support services in the community, as Dr. Bach mentioned, to do the adequate diagnosis and to find specialists in the community to make those referrals. Now, these physicians have to jump these hurdles. They don’t get paid as well. They don’t get paid as frequently. Because of encumbrances within the Medicare payment system. So, the recommendations are that there needs to be improved resources in those communities, particularly the safety net hospitals.

JUAN GONZALEZ: Dr. Bach, we have about 30 seconds, your recommendations about what might be done to equalize treatment?

DR. PETER BACH: I have to say, I concur with Dr. Price in his recommendations. I want to clarify a small point, so your readers know what our study found. Although it’s true that Black and minority physicians provide a larger percentage of care to Black patients than they do to white patients, only a minority of the physicians in our study, only about one in five of those treating Black patients were actually Black physicians. So, I don’t want your readers to mistake a study that is about the care of Black patients, and assume that what we’re talking about is therefore, Black physicians treating Black patients. They comprise an important but small segment of all of the care provided to those patients. I’d like to make that point.

JUAN GONZALEZ: Yes. I’d like to thank both of you for being with us today. Dr. Peter Bach, lead author of the study, "Primary Care Physicians Who Treat Blacks and Whites," published this month in the New England Journal of Medicine, and Dr. Winston Price, president of the National Medical Association.

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