Strategies to Reduce Health Disparities

Access to Services

Presenters: Robert M. Mayberry, M.P.H., Ph.D., Director, Morehouse Medical Treatment Effectiveness Center, Morehouse School of Medicine, Atlanta, GA Robin M. Weinick, Ph.D., Director, Intramural Research, Center for Primary Care Research, Agency for Healthcare Research and Quality (AHRQ), Rockville, MD

Having health insurance does not equal access. Getting in the door of a doctor's office does not equal receiving services that one needs and may have nothing to do with the intensity or the quality of the services provided.

Consistent and unequivocal differences exist in access to and use of medical care by race and ethnicity within certain disease categories, including invasive cardiac care, cancer treatment, and therapy for human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Significant racial disparities have also been demonstrated between black and white Medicaid and Medicare beneficiaries.

For example, health services utilization for Medicaid-enrolled children with asthma demonstrates disparities in likelihood of receiving the following services:

• Emergency department visits (black children 70 percent more likely).
• Office visits (black children 52 percent less likely).
• Prescriptions (similarly likely).
• Well-child visits (similarly likely).

Striking differences between black and white Medicare beneficiaries include the likelihood of receiving or experiencing the following:

• Ambulatory care visits (black beneficiaries 17 percent less likely).
• Mammography (black beneficiaries 25 percent less likely).
• Coronary angioplasty (black beneficiaries 49 percent less likely).
• Reduction of hip fracture (black beneficiaries 57 percent less likely).
• Bilateral orchiectomy (black beneficiaries 130 percent more likely).
• Lower limb amputation (black beneficiaries 230 percent more likely).

Existing research is very good at quantifying disparities but far less accomplished at explaining why the disparities exist. The reasons for racial and ethnic disparities in care are varied, complex, and poorly understood. Factors that do not explain ethnic differences in access to certain types of treatment include:

• Socioeconomic status.
• Insurance coverage.
• Health status.
• Severity of disease.
• Availability of services.
• Patient preferences.

Factors that may explain ethnic differences in access to certain types of medical treatment include:

• Culture.
• Cultural perceptions.
• Cultural differences.
• Provider bias.
• Racism.

Suggested strategies for reducing racial and ethnic disparities in access to and use of medical care include:

• Acknowledging racial and ethnic disparities.
• Building an appropriate knowledge base for better understanding and effective interventions.
• Targeting resources appropriately to vulnerable groups.
• Developing community and private-public partnerships (e.g., immunization, cancer screening).
• Establishing and promoting accountability measures and holding medical care systems and providers accountable for results.

Building an appropriate knowledge base provides a way to monitor disparities and to determine whether things are changing. However, this can present several challenges and considerations:

• What are the costs associated with collecting data? Data collection can be very costly, posing a significant barrier to studying racial and ethnic disparities especially among subgroups within racial or ethnic groups.
• Where do the data come from? Survey data often include self-identified information on race and ethnicity, while administrative data may be more likely to reflect the recordings of administrative clerks.
• Do the data give you the ability to identify and study subgroups? Differences within groups are often as large or larger than differences between groups. Without a large enough sample, subpopulations are difficult to study. However, larger samples increase both the cost and time needed to collect the data. Consequently, the size of a study sample often has an impact on the amount of data that can be collected.
• What are the trade-offs between breadth versus depth of data? National surveys are often so costly that they must meet many users' needs and cannot look in depth at any given topic. In-depth surveys meet very specific needs but are often very small in scale; consequently, one cannot always make generalizations from the findings.
• Can multiple data sources be combined? Caution must be used when combining multiple data sources because different sources may capture information on race and ethnicity differently. Each data source provides a different part of the picture, but their use requires an understanding of whether they measure the same thing.
• What are the associated political and social challenges? The biggest challenges when dealing with data on race and ethnicity are political and social. For example, managed care organizations (MCOs) often fear collecting data on race and ethnicity (either at enrollment or at every encounter) for fear of alienating potential enrollees and providers.

Building the knowledge base also allows the study of appropriate use of care among racial and ethnic groups.

Serious attempts to reduce disparities require thinking about the constructs and mechanisms that underlie race. The color of a person's skin has very little to do with his or her biological health status. With a few exceptions, no genetic basis for race exists. So "race" becomes a proxy for a number factors related to disparities:

• Income and resources.
• Education.
• Health insurance coverage.
• Language differences.
• Immigration status.
• Environmental issues.
• Culture.
• Type of job.
• Self-care behaviors.
• Trust.
• Geographic distribution (consumers and providers).
• Segregation, discrimination, and racism (blatant, unintentional, and institutional).
• Other disparities that may be intertwined with racial and ethnic disparities.

Understanding why disparities exist is important in identifying effective solutions and applying them to the group experiencing the disparity. Not answering the "why" question is an appropriate response when one can clearly identify what works to reduce the disparity. However, not understanding why may make determining effective solutions more difficult.

Additional Resources

Henry J. Kaiser Family Foundation. Key facts: Race, ethnicity and medical care. Menlo Park (CA): The Foundation; 1999 Oct.

Leiyu S. Experience of primary care by racial and ethnic groups in the United States. Med Care 1999;37(10):1068-77.

Mayberry RM, Mili F, Vaid IGM, et al. A synthesis of the literature: Racial and ethnic differences in access to medical care. Atlanta (GA): Morehouse Medical Treatment Effectiveness Center, Morehouse School of Medicine; 1999 Oct.

Weinick RM, Krauss NA. Racial/ethnic differences in children's access to care. Am J Pub Health 2000;90(11):1771-74.

Zuvekas SH, Weinick RM. Changes in access to care, 1977-1996: the role of health insurance. Washington (DC): Health Services Research 1999 Apr.

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