Panel discussions like “Sick and Tired: The Quality of Health Services for Minorities” about disparities in America’s health care system continue to resonate because minorities, African-Americans in particular, continue to receive substandard treatment.
The discussion, which was led by University of Pittsburgh professor and chair of the Department of Family Medicine, Jeannette South-Paul, and Johns Hopkins University professor and director of the Hopkins Center for Health Disparities Solutions, Thomas A. LaVeist, was part of a weekend- long national conference held on campus in the University Club from June 3-6. The conference, “Race in America: Restructuring Inequality,” was hosted by the University of Pittsburgh’s School of Social Work and Center on Race and Social Problems.
South-Paul and LaVeist each spoke in turn about failed efforts to close the gap between African-Americans—and other minorities—and Whites in the American health care system and to suggest possible solutions.
Issues that fuel the perpetuation of these disparities are lack of financial resources, lack of knowledge and understanding, bias, and an overall lack of primary care physicians, particularly minority physicians.
For example, the fact that doctors are required to treat patients at their own expense, to include providing interpreters for non-English speaking patients, leads many of them to refuse to see patients on Medicare, medical assistance or who don’t speak English.
“Every patient I see, I lose money on. Every single patient. I don’t get paid to cover my expenses to see a poor patient,” South-Paul explained during the Q&A part of the discussion, “so as a department chair, I try to patch together different sources of income so I’m not too much in the red, and hoping the institution I work with will continue to support me. Now you add upon that that I need an interpreter. …”
South-Paul used the example of a community PCP, lacking the resources to hire an interpreter to help him communicate with poor, non-English speaking patients, to illustrate her point. She went on to suggest that rather than penalize physicians who refuse to see poor patients, there should instead be incentives—possibly a revamping of the current reimbursement system—offered that would make it worth a physician’s while to treat poor and elderly patients. “We’re going to have to re-look at what we pay for specialty work vs. what we pay for primary care work because if you want to change health status indicators, it’s not how many cardiologists are available for a patient, it’s how many primary care physicians are available,” she explained. We’re going to have to shift the pull of how we reimburse depending on the services we provide. We don’t get reimbursed to talk to patients, we get reimbursed to treat patients, and those are some of the things we’re going to have to [try to change].”
Lack of knowledge about how to treat minority patients coupled with a dearth of minority physicians are two more causes of treatment disparities, pointed out audience member Georgette Powell of the Greater Pittsburgh Community Food Bank, who’s also a nurse.
“I think we have to start by training medical students, nursing students, pharmacy students, dental students…everyone who touches the health care system” South-Paul recommended. “And we have to do it early and often. We don’t give one lecture on diabetes and expect that that’s going to be sufficient before you get your terminal degree and then for the rest of your life. You get diabetes [lectures] every month of your training no matter what your health care discipline is and the same thing has to do with cultural competence issues and disparities. We have to train the student, the intern, the resident, the practicing clinician, and have continuing education.”
South-Paul mentioned two states, New Jersey and California, that currently require physicians to obtain cultural competency training to maintain their licenses. In addition, LaVeist is part of a joint task force with the AAMC and the Association of the School of Public Health to “develop core competencies for public health and medicine” and social competence is expected to be part of the report LaVeist said is due out later this year.
Dr. Rhonda Johnson, medical director at Highmark Blue Cross/Blue Shield, who leads Highmark’s health equity and quality services team, said it was important to attend the conference because “this is the work that we do, trying to reduce disparities. A lot of the issues that were addressed here (at the Sick and Tired panel discussion), we are [already doing],” she said. “We have programs teaching doctors how to be more culturally sensitive; we have programs to pay physicians to help them perform better in primary care settings; we have initiatives to improve the health of our members and communities. So, Highmark is already working in this regard.”
Finally, racism is a contributing factor to the disparities of treatment in the American health care system.
“I think that most [health care providers] are not racist, are not saying, ‘Well, this is a Black patient so I’m not going to give them the same quality of care.’ I think most of what happens, in terms of bias, happens on a more subconscious level. It’s an unconscious bias. I think the overall majority are in that category.”
The difficulty in addressing unconscious bias lies in the inability to readily identify it. Detection is further stymied by the fact that disparities are more easily identified “across systems” than they are in individual institutions. Because there are some hospitals that serve patients inequitably,” LaVeist suggests that a possible solution would be to study those places that have “inclusive” cultures and try to spread their philosophies and/or practices throughout the health care system as a way to see improvement.
“We have a lot of conferences for race and health but those conferences are usually just among people in health care. This conference is very different; it’s bringing together different perspectives from people with expertise in different areas…higher education, K-12 education, wealth creation,” said LaVeist. “I think that that interaction is helpful. And we’ll start to see that, in reality, we’re all studying the same underlying problem, and that we need to be communicating more. So, I think this conference will be helpful.”