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Summary
ABSTRACT
Racial and ethnic minorities tend to receive a lower quality of healthcare
than non-minorities, even when access-related factors, such as patients’ insur-
ance status and income, are controlled. The sources of these disparities are com-
plex, are rooted in historic and contemporary inequities, and involve many par-
ticipants at several levels, including health systems, their administrative and
bureaucratic processes, utilization managers, healthcare professionals, and pa-
tients. Consistent with the charge, the study committee focused part of its analy-
sis on the clinical encounter itself, and found evidence that stereotyping, biases,
and uncertainty on the part of healthcare providers can all contribute to unequal
treatment. The conditions in which many clinical encounters take place—char-
acterized by high time pressure, cognitive complexity, and pressures for cost-
containment—may enhance the likelihood that these processes will result in care
poorly matched to minority patients’ needs. Minorities may experience a range
of other barriers to accessing care, even when insured at the same level as whites,
including barriers of language, geography, and cultural familiarity. Further,
financial and institutional arrangements of health systems, as well as the legal,
regulatory, and policy environment in which they operate, may have disparate
and negative effects on minorities’ ability to attain quality care.
A comprehensive, multi-level strategy is needed to eliminate these dispari-
ties. Broad sectors—including healthcare providers, their patients, payors, health
plan purchasers, and society at large—should be made aware of the healthcare
gap between racial and ethnic groups in the United States. Health systems should
1
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2 UNEQUAL TREATMENT
base decisions about resource allocation on published clinical guidelines, insure
that physician financial incentives do not disproportionately burden or restrict
minority patients’ access to care, and take other steps to improve access—includ-
ing the provision of interpretation services, where community need exists. Eco-
nomic incentives should be considered for practices that improve provider-patient
communication and trust, and reward appropriate screening, preventive, and
evidence-based clinical care. In addition, payment systems should avoid frag-
mentation of health plans along socioeconomic lines.
The healthcare workforce and its ability to deliver quality care for racial and
ethnic minorities can be improved substantially by increasing the proportion of
underrepresented U.S. racial and ethnic minorities among health professionals.
In addition, both patients and providers can benefit from education. Patients
can benefit from culturally appropriate education programs to improve their
knowledge of how to access care and their ability to participate in clinical-deci-
sion making. The greater burden of education, however, lies with providers.
Cross-cultural curricula should be integrated early into the training of future
healthcare providers, and practical, case-based, rigorously evaluated training
should persist through practitioner continuing education programs. Finally,
collection, reporting, and monitoring of patient care data by health plans and
federal and state payors should be encouraged as a means to assess progress in
eliminating disparities, to evaluate intervention efforts, and to assess potential
civil rights violations.
Looking gaunt but determined, 59-year-old Robert Tools was intro-
duced on August 21, 2001, as a medical miracle—the first surviving
recipient of a fully implantable artificial heart. At a news conference, Tools
spoke with emotion about his second chance at life and the quality of his
care. His physicians looked on with obvious affection, grateful and hon-
ored to have extended Tools’ life. Mr. Tools has since lost his battle for
life, but will be remembered as a hero for undergoing an experimental
technology and paving the way for other patients to undergo the proce-
dure. Moreover, the fact that Tools was African American and his doctors
were white seemed, for most Americans, to symbolize the irrelevance of
race in 2001. According to two recent polls, a significant majority of
Americans believe that blacks like Tools receive the same quality of
healthcare as whites (Lillie-Blanton et al., 2000; Morin, 2001).
Behind these perceptions, however, lies a sharply contrasting reality.
A large body of published research reveals that racial and ethnic minori-
ties experience a lower quality of health services, and are less likely to
receive even routine medical procedures than are white Americans. Rela-
tive to whites, African Americans—and in some cases, Hispanics—are less
likely to receive appropriate cardiac medication (e.g., Herholz et al., 1996)
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3
SUMMARY
or to undergo coronary artery bypass surgery (e.g., Ayanian et al., 1993;
Hannan et al., 1999; Johnson et al., 1993; Petersen et al., 2002), are less
likely to receive peritoneal dialysis and kidney transplantation (e.g.,
Epstein et al., 2000; Barker-Cummings et al., 1995; Gaylin et al., 1993), and
are likely to receive a lower quality of basic clinical services (Ayanian et
al., 1999) such as intensive care (Williams et al., 1995), even when varia-
tions in such factors as insurance status, income, age, co-morbid condi-
tions, and symptom expression are taken into account. Significantly, these
differences are associated with greater mortality among African-Ameri-
can patients (Peterson et al., 1997; Bach et al., 1999).
STUDY CHARGE AND COMMMITTEE ASSUMPTIONS
These disparities prompted Congress to request an Institute of Medi-
cine (IOM) study to assess differences in the kinds and quality of health-
care received by U.S. racial and ethnic minorities and non-minorities.
Specifically, Congress requested that the IOM:
• 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 health-
care, 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.
This Executive Summary presents only abbreviated versions of the
study committee’s findings and recommendations. For the full findings
and recommendations, and a more extensive justification of each, the
reader is referred to the committee report. Below, findings and recom-
mendations are preceded by text summarizing the evidence base from
which they are drawn. For purposes of clarity, some findings and recom-
mendations are presented in a different sequence than they appear in the
full report; however, their numeric designation remains the same.
Defining Racial and Ethnic Healthcare Disparities
The study committee defines disparities in healthcare as racial or eth-
nic differences in the quality of healthcare that are not due to access-
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4 UNEQUAL TREATMENT
Clinical Appropriateness
and Need
Patient Preferences
Difference The Operation of
Quality of Health Care
Healthcare Systems and
Non-Minority
Legal and Regulatory
Climate
Disparity
Discrimination:
Minority
Biases, Stereotyping,
and Uncertainty
FIGURE S-1 Differences, disparities, and discrimination: Populations with equal
access to healthcare. SOURCE: Gomes and McGuire, 2001.
related factors or clinical needs, preferences,1 and appropriateness of in-
tervention (Figure S-1). The committee’s analysis is focused at two levels:
1) the operation of healthcare systems and the legal and regulatory cli-
mate in which health systems function; and 2) discrimination at the indi-
vidual, patient-provider level. Discrimination, as the committee uses the
term, refers to differences in care that result from biases, prejudices, ste-
reotyping, and uncertainty in clinical communication and decision-mak-
ing. It should be emphasized that these definitions are not legal defini-
tions. Different sources of federal, state and international law define
discrimination in varying ways, with some focusing on intent and others
emphasizing disparate impact.
1The committee defines patient preferences as patients’ choices regarding healthcare that
are based on a full and accurate understanding of treatment options. As discussed in Chap-
ter 3 of this report, patients’ understanding of treatment options is often shaped by the
quality and content of provider-patient communication, which in turn may be influenced by
factors correlated with patients’ and providers’ race, ethnicity, and culture. Patient prefer-
ences that are not based on a full and accurate understanding of treatment options may
therefore be a source of racial and ethnic disparities in care. The committee recognizes that
patients’ preferences and clinicians’ presentation of clinical information and alternatives in-
fluence each other, but found separation of the two to be analytically useful.
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SUMMARY
EVIDENCE OF HEALTHCARE DISPARITIES
Evidence of racial and ethnic disparities in healthcare is, with few
exceptions, remarkably consistent across a range of illnesses and health-
care services. These disparities are associated with socioeconomic differ-
ences and tend to diminish significantly, and in a few cases, disappear
altogether when socioeconomic factors are controlled. The majority of
studies, however, find that racial and ethnic disparities remain even after
adjustment for socioeconomic differences and other healthcare access-
related factors (for more extensive reviews of this literature, see Kressin
and Petersen, 2001; Geiger, this volume; and Mayberry, Mili, and Ofili, 2000).
Studies of racial and ethnic differences in cardiovascular care provide
some of the most convincing evidence of healthcare disparities. The most
rigorous studies in this area assess both potential underuse and overuse
of services and appropriateness of care by controlling for disease severity
using well-established clinical and diagnostic criteria (e.g., Schneider et
al., 2001; Ayanian et al., 1993; Allison et al., 1996; Weitzman et al., 1997) or
matched patient controls (Giles et al., 1995). Several studies, for example,
have assessed differences in treatment regimen following coronary an-
giography, a key diagnostic procedure. These studies have demonstrated
that differences in treatment are not due to clinical factors such as racial
differences in the severity of coronary disease or overuse of services by
whites (e.g., Schneider et al., 2001; Laouri et al., 1997; Canto et al., 2000;
Peterson et al., 1997). Further, racial disparities in receipt of coronary
revascularization procedures are associated with higher mortality among
African Americans (Peterson et al., 1997).
Healthcare disparities are also found in other disease areas. Several
studies demonstrate significant racial differences in the receipt of appro-
priate cancer diagnostic tests (e.g., McMahon et al., 1999), treatments (e.g.,
Imperato et al., 1996), and analgesics (e.g., Bernabei et al., 1998), while
controlling for stage of cancer at diagnosis and other clinical factors. As
is the case in studies of cardiovascular disease, evidence suggests that
disparities in cancer care are associated with higher death rates among
minorities (Bach et al., 1999). Similarly, African Americans with HIV in-
fection are less likely than non-minorities to receive antiretroviral therapy
(Moore et al., 1994), prophylaxis for pneumocystic pneumonia, and pro-
tease inhibitors (Shapiro et al., 1999). These disparities remain even after
adjusting for age, gender, education, CD4 cell count, and insurance cover-
age (e.g., Shapiro et al., 1999). In addition, differences in the quality of
HIV care are associated with poorer survival rates among minorities, even
at equivalent levels of access to care (Bennett et al., 1995; Cunningham et
al., 2000).
Racial and ethnic disparities are found in a range of other disease and
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6 UNEQUAL TREATMENT
health service categories, including diabetes care (e.g., Chin, Zhang, and
Merrell, 1998), end-stage renal disease and kidney transplantation (e.g.,
Epstein et al., 2000; Kasiske, London, and Ellison, 1998; Barker-Cummings
et al., 1995; Ayanian et al., 1999), pediatric care and maternal and child
health, mental health, rehabilitative and nursing home services, and many
surgical procedures. In some instances, minorities are more likely to re-
ceive certain procedures. As in the case of bilateral orchiectomy and am-
putation, however (which African Americans undergo at rates 2.4 and 3.6
times greater, respectively, than their white Medicare peers; Gornick et
al., 1996), these are generally less desirable procedures.
Finding 1-1: Racial and ethnic disparities in healthcare exist and,
because they are associated with worse outcomes in many cases, are
unacceptable.
Recommendation 2-1: Increase awareness of racial and ethnic
disparities in healthcare among the general public and key stake-
holders.
Recommendation 2-2: Increase healthcare providers’ awareness of
disparities.
RACIAL ATTITUDES AND DISCRIMINATION
IN THE UNITED STATES
By way of context, it is important to note that racial and ethnic dis-
parities are found in many sectors of American life. African Americans,
Hispanics, American Indians, and Pacific Islanders, and some Asian-
American subgroups are disproportionately represented in the lower so-
cioeconomic ranks, in lower quality schools, and in poorer-paying jobs.
These disparities can be traced to many factors, including historic pat-
terns of legalized segregation and discrimination. Unfortunately, some
discrimination remains. For example, audit studies of mortgage lending,
housing, and employment practices using paired “testers” demonstrate
persistent discrimination against African Americans and Hispanics. These
studies illustrate that much of American social and economic life remains
ordered by race and ethnicity, with minorities disadvantaged relative to
whites. In addition, these findings suggest that minorities’ experiences in
the world outside of the healthcare practitioner’s office are likely to affect
their perceptions and responses in care settings.
Finding 2-1: Racial and ethnic disparities in healthcare occur in the
context of broader historic and contemporary social and economic
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SUMMARY
inequality, and evidence of persistent racial and ethnic discrimina-
tion in many sectors of American life.
ASSESSING POTENTIAL SOURCES OF DISPARITIES IN CARE
The studies cited above suggest that a range of patient-level, provider-
level, and system-level factors may be involved in racial and ethnic
healthcare disparities, beyond access-related factors.
Patient-Level Variables:
The Role of Preferences, Treatment Refusal, and the
Clinical Appropriateness of Care
Racial and ethnic disparities in care may emerge, at least in part, from
a number of patient-level attributes. For example, minority patients are
more likely to refuse recommended services (e.g., Sedlis et al., 1997), ad-
here poorly to treatment regimens, and delay seeking care (e.g., Mitchell
and McCormack, 1997). These behaviors and attitudes can develop as a
result of a poor cultural match between minority patients and their pro-
viders, mistrust, misunderstanding of provider instructions, poor prior
interactions with healthcare systems, or simply from a lack of knowledge
of how to best use healthcare services. However, racial and ethnic differ-
ences in patient preferences and care-seeking behaviors and attitudes are
unlikely to be major sources of healthcare disparities. For example, while
minority patients have been found to refuse recommended treatment
more often than whites, differences in refusal rates are small and have not
fully accounted for racial and ethnic disparities in receipt of treatments
(Hannan et al., 1999; Ayanian et al., 1999). Overuse of some clinical ser-
vices (i.e., use of services when not clinically indicated) may be more com-
mon among white than minority patients, and may contribute to racial
and ethnic differences in discretionary procedures. Several recent stud-
ies, however, have assessed racial differences relative to established crite-
ria (Hannan et al., 1999; Laouri et al., 1997; Canto et al., 2000; Peterson et
al., 1997) or objective diagnostic information, and still find racial differ-
ences in receipt of care. Other studies find that overuse of cardiovascular
services among whites does not explain racial differences in service use
(Schneider et al., 2001).
Finally, some researchers have speculated that biologically based ra-
cial differences in clinical presentation or response to treatment may jus-
tify racial differences in the type and intensity of care provided. For ex-
ample, racial and ethnic group differences are found in response to drug
therapies such as enalapril, an angiotensin-converting–enzyme inhibitor
used to reduce the risk of heart failure (Exner et al., 2001). These differ-
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8 UNEQUAL TREATMENT
ences in response to drug therapy, however, are not due to “race” per se
but can be traced to differences in the distribution of polymorphic traits
between population groups (Wood, 2001), and are small in relation to the
common benefits of most therapeutic interventions. Further, as noted
above, the majority of studies document disparities in healthcare services
and disease areas when interventions are equally effective across popula-
tion groups—making the “racial differences” hypothesis an unlikely ex-
planation for observed disparities in care.
Finding 4-2: A small number of studies suggest that racial and eth-
nic minority patients are more likely than white patients to refuse
treatment. These studies find that differences in refusal rates are
generally small and that minority patient refusal does not fully ex-
plain healthcare disparities.
Healthcare Systems-Level Factors
Aspects of health systems—such as the ways in which systems are
organized and financed, and the availability of services—may exert dif-
ferent effects on patient care, particularly for racial and ethnic minorities.
Language barriers, for example, pose a problem for many patients where
health systems lack the resources, knowledge, or institutional priority to
provide interpretation and translation services. Nearly 14 million Ameri-
cans are not proficient in English, and as many as one in five Spanish-
speaking Latinos reports not seeking medical care due to language
barriers (The Robert Wood Johnson Foundation, 2001). Similarly, time
pressures on physicians may hamper their ability to accurately assess pre-
senting symptoms of minority patients, especially where cultural or lin-
guistic barriers are present. Further, the geographic availability of health-
care institutions—while largely influenced by economic factors that are
outside the charge of this study—may have a differential impact on racial
and ethnic minorities, independent of insurance status (Kahn et al., 1994).
A study of the availability of opioid supplies, for example, revealed that
only one in four pharmacies located in predominantly non-white neigh-
borhoods carried adequate supplies, compared with 72% of pharmacies
in predominantly white neighborhoods (Morrison et al., 2000). Perhaps
more significantly, changes in the financing and delivery of healthcare
services—such as the shifts brought by cost-control efforts and the move-
ment to managed care—may pose greater barriers to care for racial and
ethnic minorities than for non-minorities (Rice, this volume). Increasing
efforts by states to enroll Medicaid patients in managed care systems, for
example, may disrupt traditional community-based care and displace pro-
viders who are familiar with the language, culture, and values of ethnic
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SUMMARY
minority communities (Leigh, Lillie-Blanton, Martinez, and Collins, 1999).
In addition, research indicates that minorities enrolled in publicly funded
managed care plans are less likely to access services after mandatory en-
rollment in an HMO, compared with whites and other minorities enrolled
in non-managed care plans (Tai-Seale et al., 2001).
Care Process-Level Variables:
The Role of Bias, Stereotyping, Uncertainty
Three mechanisms might be operative in healthcare disparities from
the provider’s side of the exchange: bias (or prejudice) against minorities;
greater clinical uncertainty when interacting with minority patients; and
beliefs (or stereotypes) held by the provider about the behavior or health
of minorities (Balsa and McGuire, 2001). Patients might also react to pro-
viders’ behavior associated with these practices in a way that also contrib-
utes to disparities. Unfortunately, little research has been conducted to
elucidate how patient race or ethnicity may influence physician decision-
making and how these influences affect the quality of care provided. In
the absence of such research, the study committee drew upon a mix of
theory and relevant research to understand how clinical uncertainty, bi-
ases or stereotypes, and prejudice might operate in the clinical encounter.
Clinical Uncertainty
Any degree of uncertainty a physician may have relative to the condi-
tion of a patient can contribute to disparities in treatment. Doctors must
depend on inferences about severity based on what they can see about the
illness and on what else they observe about the patient (e.g., race). The
doctor can therefore be viewed as operating with prior beliefs about the
likelihood of patients’ conditions, “priors” that will be different according
to age, gender, socioeconomic status, and race or ethnicity. When these
priors—which are taught as a cognitive heuristic to medical students—
are considered alongside the information gained in a clinical encounter,
both influence medical decisions.
Doctors must balance new information gained from the patient (some-
times with varying levels of accuracy) and their prior expectations about
the patient to determine the diagnosis and course of treatment. If the
physician has difficulty accurately understanding the symptoms or is less
sure of the “signal”—the set of clues and indications that physicians rely
upon to make diagnostic decisions—then he or she is likely to place
greater weight on the “priors.” The consequence is that treatment deci-
sions and patients’ needs are potentially less well matched.
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10 UNEQUAL TREATMENT
The Implicit Nature of Stereotypes
A large body of research in psychology has explored how stereotypes
evolve, persist, shape expectations, and affect interpersonal interactions.
Stereotyping can be defined as the process by which people use social
categories (e.g., race, sex) in acquiring, processing, and recalling informa-
tion about others. The beliefs (stereotypes) and general orientations (atti-
tudes) that people bring to their interactions help to organize and sim-
plify complex or uncertain situations and give perceivers greater
confidence in their ability to understand a situation and respond in effi-
cient and effective ways (Mackie, Hamilton, Susskind, and Rosselli, 1996).
Although functional, social stereotypes and attitudes also tend to be
systematically biased. These biases may exist in overt, explicit forms, as
represented by traditional bigotry. However, because their origins arise
from virtually universal social categorization processes, they may also
exist, often unconsciously, among people who strongly endorse egalitar-
ian principles and truly believe that they are not prejudiced (Dovidio and
Gaertner, 1998). In the United States, because of shared socialization in-
fluences, there is considerable empirical evidence that even well-meaning
whites who are not overtly biased and who do not believe that they are
prejudiced typically demonstrate unconscious implicit negative racial at-
titudes and stereotypes (Dovidio, Brigham, Johnson, and Gaertner, 1996).
Both implicit and explicit stereotypes significantly shape interpersonal
interactions, influencing how information is recalled and guiding expec-
tations and inferences in systematic ways. They can also produce self-
fulfilling prophecies in social interaction, in that the stereotypes of the
perceiver influence the interaction with others in ways that conform to
stereotypical expectations (Jussim, 1991).
Healthcare Provider Prejudice or Bias
Prejudice is defined in psychology as an unjustified negative attitude
based on a person’s group membership (Dovidio et al., 1996). Survey
research suggests that among white Americans, prejudicial attitudes to-
ward minorities remain more common than not, as over half to three-
quarters believe that relative to whites, minorities—particularly African
Americans—are less intelligent, more prone to violence, and prefer to live
off of welfare (Bobo, 2001). It is reasonable to assume, however, that the
vast majority of healthcare providers find prejudice morally abhorrent
and at odds with their professional values. But healthcare providers, like
other members of society, may not recognize manifestations of prejudice
in their own behavior.
While there is no direct evidence that provider biases affect the qual-
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SUMMARY
ity of care for minority patients, research suggests that healthcare provid-
ers’ diagnostic and treatment decisions, as well as their feelings about
patients, are influenced by patients’ race or ethnicity. Schulman et al.
(1999), for example, found that physicians referred white male, black male,
and white female hypothetical “patients” (actually videotaped actors who
displayed the same symptoms of cardiac disease) for cardiac catheteriza-
tion at the same rates (approximately 90% for each group), but were sig-
nificantly less likely to recommend catheterization procedures for black
female patients exhibiting the same symptoms. Weisse et al. (2001), using
a similar methodology as that of Schulman, found that male physicians
prescribed twice the level of analgesic medication for white “patients”
than for black “patients.” Female physicians, in contrast, prescribed
higher doses of analgesics for black than for white “patients,” suggesting
that male and female physicians may respond differently to gender and/
or racial cues. In another experimental design, Abreu (1999) found that
mental health professionals subliminally “primed” with African Ameri-
can stereotype-laden words were more likely to evaluate the same hypo-
thetical patient (whose race was not identified) more negatively than when
primed with neutral words. And in a study based on actual clinical en-
counters, van Ryn and Burke (2000) found that doctors rated black pa-
tients as less intelligent, less educated, more likely to abuse drugs and
alcohol, more likely to fail to comply with medical advice, more likely to
lack social support, and less likely to participate in cardiac rehabilitation
than white patients, even after patients’ income, education, and personal-
ity characteristics were taken into account. These findings suggest that
while the relationship between race or ethnicity and treatment decisions
is complex and may also be influenced by gender, providers’ perceptions
and attitudes toward patients are influenced by patient race or ethnicity,
often in subtle ways.
Medical Decisions Under Time Pressure with Limited Information
Studies suggest that several characteristics of the clinical encounter
increase the likelihood that stereotypes, prejudice, or uncertainly may in-
fluence the quality of care for minorities (van Ryn, 2002). In the process of
care, health professionals must come to judgments about patients’ condi-
tions and make decisions about treatment, often without complete and
accurate information. In most cases, they must do so under severe time
pressure and resource constraints. The assembly and use of these data are
affected by many influences, including various “gestalts” or cognitive
shortcuts. In fact, physicians are commonly trained to rely on clusters of
information that functionally resemble the application of “prototypic” or
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18 UNEQUAL TREATMENT
1999; Jackson and Parks, 1997). In addition, some evidence suggests that
lay health workers can help improve the quality of care and reduce costs
(Witmer et al., 1995), and improve general wellness by facilitating com-
munity access to and negotiation for services (Rodney et al., 1998).
Recommendation 5-10: Support the use of community health
workers.
Multidisciplinary Teams
Research demonstrates that multidisciplinary team approaches—in-
cluding physicians, nurses, dietitians, and social workers, among others—
can effectively optimize patient care. This effect is found in randomized
controlled studies of patients with coronary heart disease, hypertension,
and other diseases, and has extended to strategies for reducing risk be-
haviors and conditions such as smoking, sedentary lifestyle and obesity
(Hill and Miller, 1996). Multidisciplinary teams coordinate and stream-
line care, enhance patient adherence through follow-up techniques, and
address the multiple behavioral and social risks faced by patients. These
teams may save costs and improve the efficiency of care by reducing the
need for face-to-face physician visits and improve patients’ day-to-day
care between visits. Further, such strategies have proven effective in im-
proving health outcomes of minorities previously viewed as “difficult to
serve” (Hill and Miller, 1996). Multidisciplinary team approaches should
be more widely instituted as strategy for improving care delivery, imple-
menting secondary prevention strategies, and enhancing risk reduction.
Recommendation 5-11: Implement multidisciplinary treatment and
preventive care teams.
Patient Education and Empowerment
Increasingly, researchers are recognizing the important role of pa-
tients as active participants in clinical encounters (Korsch, 1984). Patient
education efforts have taken many forms, including the use of books and
pamphlets, in-person instruction, CD-ROM-based educational materials,
and internet-based information. These materials guide patients through
typical office visits and provide information about asking appropriate
questions and having their questions answered, communicating with the
provider when instructions are not understood or cannot be followed,
and being an active participant in decision-making. While evaluation data
are limited, particularly with respect to racial and ethnic minority patients,
preliminary evidence suggests that patient education can improve pa-
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SUMMARY
tients’ skills and knowledge of clinical encounters and improve their par-
ticipation in care decisions.
Recommendation 5-12: Implement patient education programs to
increase patients’ knowledge of how to best access care and partici-
pate in treatment decisions.
Cross-Cultural Education in the Health Professions
Given the increasing racial and ethnic diversity of the U.S. popula-
tion, the development and implementation of training programs for
healthcare providers offers promise as a key intervention strategy in re-
ducing healthcare disparities. As a result, cross-cultural education pro-
grams have been developed to enhance health professionals’ awareness
of how cultural and social factors influence healthcare, while providing
methods to obtain, negotiate and manage this information clinically once
it is obtained. Cross-cultural education can be divided into three concep-
tual approaches focusing on attitudes (cultural sensitivity/awareness ap-
proach), knowledge (multicultural/categorical approach), and skills (cross-
cultural approach), and has been taught using a variety of interactive and
experiential methodologies. Research to date demonstrates that training
Summary of Findings
Finding 1-1: Racial and ethnic disparities in healthcare exist and, because
they are associated with worse outcomes in many cases, are unacceptable.
Finding 2-1: Racial and ethnic disparities in healthcare occur in the con-
text of broader historic and contemporary social and economic inequality,
and evidence of persistent racial and ethnic discrimination in many sectors
of American life.
Finding 3-1: Many sources—including health systems, healthcare provid-
ers, patients, and utilization managers—may contribute to racial and eth-
nic disparities in healthcare.
Finding 4-1: Bias, stereotyping, prejudice, and clinical uncertainty on the
part of healthcare providers may contribute to racial and ethnic disparities
in healthcare. While indirect evidence from several lines of research sup-
ports this statement, a greater understanding of the prevalence and influ-
ence of these processes is needed and should be sought through research.
Finding 4-2: A small number of studies suggest that racial and ethnic mi-
nority patients are more likely than white patients to refuse treatment.
These studies find that differences in refusal rates are generally small and
that minority patient refusal does not fully explain healthcare disparities.
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20 UNEQUAL TREATMENT
Summary of Recommendations
General Recommendations
Recommendation 2-1: Increase awareness of racial and ethnic disparities
in healthcare among the general public and key stakeholders.
Recommendation 2-2: Increase healthcare providers’ awareness of dispari-
ties.
Legal, Regulatory, and Policy Interventions
Recommendation 5-1: Avoid fragmentation of health plans along socio-
economic lines.
Recommendation 5-2: Strengthen the stability of patient-provider relation-
ships in publicly funded health plans.
Recommendation 5-3: Increase the proportion of underrepresented U.S.
racial and ethnic minorities among health professionals.
Recommendation 5-4: Apply the same managed care protections to pub-
licly funded HMO enrollees that apply to private HMO enrollees.
Recommendation 5-5: Provide greater resources to the U.S. DHHS Office
for Civil Rights to enforce civil rights laws.
Health Systems Interventions
Recommendation 5-6: Promote the consistency and equity of care through
the use of evidence-based guidelines.
Recommendation 5-7: Structure payment systems to ensure an adequate
supply of services to minority patients, and limit provider incentives that
may promote disparities.
Recommendation 5-8: Enhance patient-provided communication and trust
by providing financial incentives for practices that reduce barriers and en-
courage evidence-based practice.
Recommendation 5-9: Support the use of interpretation services where
community need exists.
is effective in improving provider knowledge of cultural and behavioral
aspects of healthcare and building effective communication strategies.
Despite progress in the field, however, several challenges exist, including
the need to define educational core competencies, reach consensus on ap-
proaches and methodologies, determine methods of integration into the
medical and nursing curriculum, and develop and implement appropri-
ate evaluation strategies. These challenges should be addressed to realize
the potential of cross-cultural education strategies.
Recommendation 6-1: Integrate cross-cultural education into the
training of all current and future health professionals.
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21
SUMMARY
Recommendation 5-10: Support the use of community health workers.
Recommendation 5-11: Implement multidisciplinary treatment and pre-
ventive care teams.
Patient Education and Empowerment
Recommendation 5-12: Implement patient education programs to increase
patients’ knowledge of how to best access care and participate in treatment
decisions.
Cross-Cultural Education in the Health Professions
Recommendation 6-1: Integrate cross-cultural education into the training
of all current and future health professionals.
Data Collection and Monitoring
Recommendation 7-1: Collect and report data on health care access and
utilization by patients’ race, ethnicity, socioeconomic status, and where
possible, primary language.
Recommendation 7-2: Include measures of racial and ethnic disparities in
performance measurement.
Recommendation 7-3: Monitor progress toward the elimination of
healthcare disparities.
Recommendation 7-4: Report racial and ethnic data by OMB categories,
but use subpopulation groups where possible.
Research Needs
Recommendation 8-1: Conduct further research to identify sources of ra-
cial and ethnic disparities and assess promising intervention strategies.
Recommendation 8-2: Conduct research on ethical issues and other barri-
ers to eliminating disparities.
DATA COLLECTION AND MONITORING
Standardized data collection is critically important in the effort to
understand and eliminate racial and ethnic disparities in healthcare. Data
on patient and provider race and ethnicity would allow researchers to
better disentangle factors that are associated with healthcare disparities,
help health plans to monitor performance, ensure accountability to en-
rolled members and payors, improve patient choice, allow for evaluation
of intervention programs, and help identify discriminatory practices.
Unfortunately, standardized data on racial and ethnic differences in care
are generally unavailable. Federal and state-supported data collection
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22 UNEQUAL TREATMENT
efforts are scattered and unsystematic, and many health plans, with a few
notable exceptions, do not collect data on enrollees’ race, ethnicity, or pri-
mary language.
A number of ethical, logistical, and fiscal concerns present challenges
to data collection and monitoring, including the need to protect patient
privacy, the costs of data collection, and resistance from healthcare pro-
viders, institutions, plans and patients. In addition, health plans have
raised significant concerns about how such data will be analyzed and re-
ported. The challenges to data collection should be addressed, as the costs
of failing to assess racial and ethnic disparities in care may outweigh new
burdens imposed by data collection and analysis efforts.
Recommendation 7-1: Collect and report data on healthcare access
and utilization by patients’ race, ethnicity, socioeconomic status,
and where possible, primary language.
Recommendation 7-2: Include measures of racial and ethnic dis-
parities in performance measurement.
Recommendation 7-3: Monitor progress toward the elimination of
healthcare disparities.
Recommendation 7-4: Report racial and ethnic data by federally
defined categories, but use subpopulation groups where possible.
NEEDED RESEARCH
While the literature that the committee reviewed provides significant
evidence of racial and ethnic disparities in care, the evidence base from
which to better understand and eliminate disparities in care remains less
than clear. Several broad areas of research are needed to clarify how race
and ethnicity are associated with disparities in the process, structure, and
outcomes of care. Research must provide a better understanding of the
contribution of patient, provider, and institutional characteristics on the
quality of care for minorities. Research has been notably absent in other
areas. More research is needed, for example, to understand the extent of
disparities in care faced by Asian-American, Pacific-Islander, American
Indian and Alaska Native, and Hispanic populations, and to better under-
stand and surmount barriers to research on healthcare disparities, includ-
ing those related to ethical issues in data collection.
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23
SUMMARY
Recommendation 8-1: Conduct further research to identify sources
of racial and ethnic disparities and assess promising intervention
strategies.
Recommendation 8-2: Conduct research on ethical issues and other
barriers to eliminating disparities.
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