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Clinical Uncertainty and Healthcare Disparities

Published online by Cambridge University Press:  06 January 2021

Ana I. Balsa ,
Naomi Seiler ,
Thomas G. McGuire  and
M. Gregg Bloche
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Extract

The Institute of Medicine Report, Unequal Treatment: Confronting Racial and Ethnic Disparities, affirms in its first finding: “Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.” The mechanisms that generate racial and ethnic disparities in medical care operate at the levels of the healthcare system and the clinical encounter. Research demonstrates the role of healthcare system factors, including differences in insurance coverage and other determinants of healthcare access, in producing disparities. Research also shows, however, that even when insurance status and other measures of access are controlled for by statistical methods, racial and ethnic disparities persist. These disparities remain when researchers try by various methods to control for patients’ clinical characteristics. Disparities are especially well documented through comparisons between white patients and African Americans and Latinos, but they are believed to affect other minority groups. As a result, many members of minority racial and ethnic groups receive less or inferior care.

Type
Research Article
Information
American Journal of Law & Medicine , Volume 29 , Issue 2-3 , June 2003 , pp. 203 - 219
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 2003

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Footnotes

†

Research for this Article was partly supported by grant P01 MH59876 from the NIMH (Balsa and McGuire), a Greenwall Fellowship (Seiler) and a Robert Wood Johnson Investigator Award in Health Policy Research (Bloche). McGuire and Bloche were members of the Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care.

References

1 INST. OF MED., UNEQUAL TREATMENT: CONFRONTING RACIAL AND ETHNIC DISPARITIES 160-79 (2002) [hereinafter UNEQUAL TREATMENT].

2 For a comprehensive review of these findings, see UNEQUAL TREATMENT, supra note 1.

3 Wennberg, John E., On Patient Need, Equity, Supplier-Induced Demand, and the Need to Assess the Outcome of Common Medical Practices, 23 MED. CARE 512, 517 (1985)Google Scholar.

4 Arrow, Kenneth, Uncertainty and the Welfare Economics of Medical Care, 53 AM. ECON. REV. 941 (1963)Google Scholar.

5 Gregg Bloche, M., The Invention of Health Law, 91 CAL. L. REV. (forthcoming 2003)CrossRefGoogle Scholar.

6 Gregg Bloche, M., Race and Discretion in American Medicine, 1 YALE J. HEALTH POL’Y L. & ETHICS 95, 103-04 (2001)Google Scholar.

7 Arrow, supra note 4, at 951.

8 This interaction between doctor and patient can be modeled in game theory terms as a Nash equilibrium. See Balsa, Ana & McGuire, Thomas, Prejudice, Clinical Uncertainty and Stereotypes as Sources of Health Disparities, 22 J. HEALTH ECON. 89, 102-03 (2003)Google Scholar.

9 Gianakos, Dean, Accepting Limits, 158 ARCHIVES INTERNAL MED. 1059, 1059 (1998)Google Scholar.

10 See Wennberg, John E., Understanding Geographical Variations in Healthcare Delivery, 340 NEW ENG. J. MED. 52 (1999)Google Scholar.

11 See HERBERT A. SIMON, MODELS OF BOUNDED RATIONALITY: BEHAVIORAL ECONOMICS AND BUSINESS ORGANIZATION 206-07 (1982).

12 Woolf, Steven H., The Need for Perspective in Evidence-Based Medicine, 282 JAMA 2358, 2359 (1999)Google Scholar.

13 Bloche, supra note 5.

14 Id.

15 Id.

16 536 U.S. 355 (2002).

17 Id. More than forty states now have laws requiring independent medical review of insurers’ coverage denials when patients or doctors request such review.

18 Wilt, Timothy J., Uncertainty in Prostate Cancer Care: The Physician's Role in Clearing the Confusion, 283 JAMA 3258, 3259 (2000)Google Scholar.

19 Id. at 3258.

20 See, e.g., Wennberg, supra note 10. New technologies expand treatment possibilities but can also increase uncertainty. Welch et al. outline four sources of uncertainty that clinicians face in counseling patients about the results of clinical genetic tests: (1) uncertainty about who will develop the disease (because most genes have incomplete penetrance, meaning they will not result in disease in all carriers); (2) uncertainty about the extent to which the risk has been overstated (because some studies of genetic determinants of disease thus far have studied disproportionately high-risk populations); (3) uncertainty as to the right time to learn the information (because genetic markers may be detected decades before the manifestation of a disease); and (4) uncertainty about the benefits of early intervention. Gilbert Welch, H. et al., Uncertainties in Genetic Testing for Chronic Disease, 280 JAMA 1525, 1525-26 (1998)Google Scholar.

21 JOSEPH P. NEWHOUSE & THE INSURANCE EXPERIMENT GROUP, FREE FOR ALL? LESSONS FROM THE RAND HEALTH INSURANCE EXPERIMENT (1993).

22 Gruber, J. & Owings, M., Physician Financial Incentives and Cesarean Section Delivery, 27 RAND J. ECON. 99, 100 (1996)Google Scholar.

23 Bloche, supra note 6, at 104.

24 UNEQUAL TREATMENT, supra note 1, at 161.

25 Mechanic, David et al., Are Patients’ Office Visits with Physicians Getting Shorter?, 344 NEW ENG. J. MED. 198, 198 (2001)Google Scholar.

26 Dovidio, John F., Stereotyping, in THE MIT ENCYCLOPEDIA OF THE COGNITIVE SCIENCES (Wilson & Keil eds., 1999)Google Scholar.

27 Van Ryn, M. & Burke, J., The Effect of Patient Race and Socio-Economic Status on Physicians’ Perceptions of Patients, 50 SOC. SCI. & MED. 813 (2000)Google Scholar.

28 Fiske, Susan T., Stereotyping, Prejudice and Discrimination, in THE HANDBOOK OF SOCIAL PSYCHOLOGY 357–411 (Gilbert, Daniel T. et al. eds., 4th ed. 1998)Google Scholar.

29 Loewenstein, George et al., Risk as Feelings, 127 PSYCH. BULLETIN 267, 267 (2001)Google Scholar.

30 UNEQUAL TREATMENT, supra note 1, at 166.

31 Id. at 162.

32 Abreu, José M., Conscious and Nonconscious African-American Stereotypes: Impact on First Impression and Diagnostic Ratings by Therapists, 67 J. CONSULTING & CLINICAL PSYCH. 387 (1999)Google Scholar.

33 Rathore, Saif S. et al., The Effects of Patient Sex and Race on Medical Students’ Ratings of Quality of Life, 108 AM. J. MED. 561 (2000)Google Scholar.

34 MILTON C. WEINSTEIN ET AL., CLINICAL DECISION ANALYSIS (1980).

35 Benson, V. & Marano, M.A., Current Estimates from the National Health Interview Survey, 1995, 10 VITAL & HEALTH STATS. 1 (1999)Google Scholar.

36 Balsa, Ana & McGuire, Thomas, Statistical Discrimination in Health Care, 20 J. HEALTH ECON. 882 (2001)Google Scholar.

37 Bonham, Vence L., Race, Ethnicity, and Pain Treatment: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatment, 29 J.L. MED. & ETHICS 52, 52 (2001)Google Scholar.

38 Uncertainty arising from provider-patient communication may be particularly problematic in mental healthcare, where a relatively large portion of information is gained in the provider-patient exchange. Ana Balsa et al., Testing for Statistical Discrimination: An Application to Health Care Disparities (2002), available at http://www.hcp.med.harvard.edu/people/faculty/mcguire.html. This has an important implication for the effort to achieve parity between mental health and other medical insurance coverage: provider payment schemes and institutional arrangements that fail to address obstacles to provider-patient communication may engender especially wide racial and ethnic disparities in mental healthcare.

39 Komaromy, Miriam et al., The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations, 334 NEW ENG. J. MED. 1305 (1996)Google Scholar; Moy, Ernest & Bartman, Barbara A., Physician Race and Care of Minority and Medically Indigent Patients, 273 JAMA 1515 (1995)Google Scholar.

40 Breaux, N. & Ryujin, D., Use of Mental Health Services by Ethnically Diverse Groups Within the United States, 52 CLINICAL PSYCH. 4 (1999)Google Scholar; Snowden, Lonnie R., African American Service Use for Mental Health Problems, 27 J. CMTY. PSYCH. 303 (1999)Google Scholar.

41 Balsa & McGuire, supra note 36.

42 Exactly the same conclusions apply when poor interpretations of symptoms result from the application of screening instruments that are not culturally valid for certain populations.

43 Benson & Marano, supra note 35.

44 Lin, K.M. et al., The Use of Psychotropic Medications in Working with Asian Patients, in WORKING WITH ASIAN AMERICANS: A GUIDE FOR CLINICIANS (1997)Google Scholar.

45 Balsa & McGuire, supra note 8.

46 U.S. DEP't OF HEALTH & HUMAN SERVS., HEALTHY PEOPLE 2010 (2000); NAT’L INST. OF HEALTH, STRATEGIC RESEARCH PLAN TO REDUCE AND ULTIMATELY ELIMINATE HEALTH DISPARITIES, FISCAL YEARS 2002-2006 (draft, Oct. 6, 2000).

47 In some cases, though, higher severity may lead to less appropriateness of use of a certain procedure. The presence of many co-morbidities reduces the likelihood of late angiography on patients with acute myocardial infarction. Balsa & Guadagnoli (2003) (untitled, unpublished manuscript, Harvard Medical School, on file with author).

48 Even if the prevalence or outcome statistics on which a provider relies are accurate, these adjustments might contribute to clinically irrational disparities in health status. Bowser argues that providers’ reliance on differential prevalence (and outcome) data for different ethnic groups creates a sense of “these people just don't do well” that contributes to continued under-treatment or undervaluation of minority patients’ well-being. Bowser, Rene, Racial Bias in Medical Treatment, 105 DICK. L. REV. 365 (2001)Google Scholar.

49 Schecter, Allison D. et al., Influence of Gender, Race and Education on Patient Preferences and Receipt of Cardiac Catheterizations Among Coronary Care Unit Patients, 78 AM. J. CARDIOLOGY 996 (1996)Google Scholar; Sedlis, Steven P. et al., Racial Differences in Performance of Invasive Cardiac Procedures in a Department of Veterans’ Affairs Medical Center, 50 J. CLINICAL EPIDEMIOLOGY 899 (1997)Google Scholar.

50 R.C. Kessler et al., The 12-Month Prevalence and Correlates of Serious Mental Illness (SMI), in MENTAL HEALTH, UNITED STATES (R.W. Manderschield & M.A. Sonnenschein eds., HHS, Pub. No. (SMA) 96-3098, 1996); Zhang, Amy Y. et al., Differences Between Asian and White Americans’ Help Seeking and Utilization Patterns in the Los Angeles Area, 26 J. CMTY. PSYCH. 317 (1998)Google Scholar.

51 Cooper-Patrick, Lisa et al., Race, Gender and Partnership in the Patient-Physician Relationship, 282 JAMA 583 (1999)Google Scholar.

52 Saha, Somnath et al., Patient-Physician Concordance and the Perceived Quality and Use of Health Care, 159 ARCHIVES INTERNAL MED. 997 (1999)Google Scholar.

53 Sue, Stanley et al., Community Mental Health Services for Ethnic Minority Groups: A Test of the Cultural Responsiveness Hypothesis, 59 J. CONSULTING & CLINICAL PSYCHOLOGY 533 (1991)Google Scholar; Takeuchi, David T. et al., Return Rates and Outcomes from Ethnicity-Specific Mental Health Programs in Los Angeles, 85 AM. J. PUB. HEALTH 638 (1995)Google Scholar.

54 Pérez-Stable, Eliseo J. et al., The Effects of Ethnicity and Language on Medical Outcomes of Patients with Hypertension or Diabetes, 35 MED. CARE 1212 (1997)Google Scholar.

55 Chen, J. et al., Racial Differences in the Use of Cardiac Catheterization After Acute Myocardial Infarction, 344 NEW ENG. J. MED. 1443 (2001)Google Scholar.

56 Frank, Richard G. & McGuire, Thomas G., Savings from a Medicaid Carve-Out for Mental Health and Substance Abuse Services in Massachusetts, 48 PSYCH. SERVS. 1147 (1997)Google Scholar; Goldman, William et al., Cost and Use of Mental Health Services Before and After Managed Care, 17 HEALTH AFFAIRS 40 (1998)Google Scholar.

57 de Laet, David E. et al., Receipt of Preventive Services Among Privately Insured Minorities in Managed Care Versus Fee-for-Service Insurance Plans, 17 J. GEN. INTERNAL MED. 451 (2002)Google Scholar. For a similar argument, see Haas, Jennifer S. et al., Effect of Managed Care Insurance on the Use of Preventive Care for Specific Ethnic Groups in the United States, 40 MED. CARE 743 (2002)Google Scholar.

58 Schneider, Eric C. et al., Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care, 287 JAMA 1288 (2002)Google Scholar; Tai-Seale, Ming et al., Racial Disparities in Service Use Among Medicaid Beneficiaries After Mandatory Enrollment in Managed Care: A Difference in Differences Approach, 38 INQUIRY 49 (2001)Google Scholar.

59 Bloche, supra note 6.

60 No published studies in the health services research literature test this hypothesis, but effects along these lines have been observed in comparative studies of White and minority performance in mediation of legal disputes. See Waldman, Ellen, Substituting Needs for Rights in Mediation: Therapeutic or Disabling?, 5 PSYCH. PUB. POL’Y & L. 1103 (1999)Google Scholar (analyzing unpublished study results indicating that Latino and African American litigants report greater subjective satisfaction but achieve poorer economic results in mediation of small claims court disputes). A recent study of the frequency of patients’ complaints to health plans lends circumstantial support to the hypothesis. A nation-wide survey of more than 1200 adults covered by insurers other than Medicare found that Blacks and Asian Americans were about half as likely as Whites to complain to their health plans. Schlesinger, Mark et al., Voices Unheard: Barriers to Expressing Dissatisfaction to Health Plans, 80 MILBANK QUARTERLY 709, 722, 733 (2002)Google Scholar (reporting findings from the 1999 Kaiser Family Foundation National Survey on Consumer Experiences with Health Plans). This report was not accompanied by information on the extent to which these complaints arose during patients’ efforts to negotiate managed care bureaucracies in order to obtain health services.

61 Bloche, supra note 6, at 108-09.

62 Gianakos, supra note 9, at 1059.

63 See sources cited supra note 46.

64 See UNEQUAL TREATMENT, supra note 1.

65 Carla S. Gomes, Measuring Selection Incentives from Capitation and Risk Adjustment in Florida Medicaid (2002) (unpublished manuscript, Mount Sinai School of Medicine), available at http://www.latino.rcm.upr.edu (last visited Mar. 10, 2003).

66 NORMAN DANIELS, JUST HEALTH CARE (1985).

67 MICHAEL WALZER, SPHERES OF JUSTICE: A DEFENSE OF PLURALISM AND EQUALITY (1983).

68 Such measures include support for translation services, hiring of multilingual and multicultural providers, making cultural sensitivity education a standard part of medical training, and provider payment scales that reward time spent speaking and listening to patients. See UNEQUAL TREATMENT, supra note 1.

69 See id.

70 IRIS J. LAV & NICHOLAS JOHNSON, CTR. ON BUDGET & POL’Y PRIORITIES, STATE BUDGET DEFICITS FOR FISCAL YEAR 2004 ARE HUGE AND GROWING (2002), available at http://www.cbpp.org (last visited Mar. 10, 2003).

71 VERNON SMITH ET AL., KAISER COMM’N ON MEDICAID & THE UNINSURED, MEDICAID SPENDING GROWTH: A 50 STATE UPDATE FOR FISCAL YEAR 2003 (2003), available at http://www.kff.org (last visited Mar. 10, 2003).

72 See UNEQUAL TREATMENT, supra note 1.

73 See id.

74 STEVEN A. CAMAROTA & JOHN KEELEY, CTR. FOR IMMIGR. STUDIES, THE NEW ELLIS ISLANDS: EXAMINING NON-TRADITIONAL AREAS OF IMMIGRANT SETTLEMENT IN THE 1990S (2001), available at http://www.cis.org (last visited Mar. 10, 2003).