That's the conclusion of a Harvard study that appears in tomorrow's issue of the Journal of the American Medical Association. It's the latest in a string of studies to document racial disparities in health care in the United States.
"There have been more than a dozen studies in peer-reviewed articles that have shown this type of trend, so I'm convinced now that race is an independent factor in determining how people get treated," says Dr. Harold Freeman, director of the Center to Reduce Cancer Health Disparities at the National Cancer Institute. "It's a complex issue. I used to argue that poverty in itself was the driving force, but now I think you have to add race as part of the equation."Since 1997, all health plans that enroll Medicare beneficiaries have been required to report on the quality of care they provide. This annual Health Plan Employer Data and Information Set uses four measures: breast cancer screening, eye examinations for patients with diabetes, use of beta blocker medications after a heart attack, and follow-up after hospitalization for mental illness.
The data provide an unprecedented opportunity to examine quality-of-care indices among Medicare enrollees in health plans around the nation.
This latest study looked specifically at the quality of care measures for 305,547 patients over the age of 65 who were enrolled in Medicare managed-care health plans during 1997. The results showed blacks received lower quality of care on all four measures.
Only 62.9 percent of blacks received breast cancer screening versus 70.9 percent for whites; 43.6 percent of blacks with diabetes received eye examinations versus 50.4 percent for whites; 64.1 percent of blacks surveyed were given beta blockers after heart attacks versus 73.8 percent for whites; and only 33.2 percent of blacks received follow-up after hospitalization for mental illness versus 54 percent for whites.
"After statistical adjustment for other factors, the percentage point disparities were greatest for the mental health measure, and least (and no longer statistically significant) for the breast cancer measure," says lead author Dr. Eric Schneider.
Racial disparities in the number of black and whites who receive breast cancer screening have been documented in previous years, and the authors speculate this has led to conscious efforts to reduce the disparity. The much more pronounced differences in follow-up after hospitalization for mental illness have not been documented before.
The study also found that individual socioeconomic characteristics, most importantly education and income, played a role in the disparities. More than half of the racial disparity in breast cancer screening could be explained by socioeconomic factors, while less than one-tenth of the disparity in hospital follow-up was explained.
Differences in health plans occasionally played a part as well.
"It appeared that health plan performance was an important factor influencing the racial disparity in breast cancer screening, but not the other measures," Schneider says.
The study and its results form a powerful argument for continuing to gather this kind of data.
"Collecting information about the quality of care is a critical effort and should be expanded," Schneider says. "It seems that quality variations among types of services are important. Unless we document them carefully, it is very difficult to know what the best targets are for quality improvement."
Finding ways to actually improve the situation is going to be another complicated matter. "We see each other in this great nation of ours through the lens of race, and the lens goes both ways," Freeman says. "We don't know what part of it is bias versus how patients behave, whether patients are offering some barrier on their own to receiving treatment, like belief systems and culture."
On the other hand, Freeman adds, physicians could also be making assumptions when they see a 58-year-old black male. Is he going to follow my directions? Should I give him this expensive treatment, or is it going to be wasted?
"That's not completely sorted out but even if that were so, the burden for following through has to be placed on the back of the caregiver," Freeman says.
Schneider seems to agree.
"Trust between the practitioner and the patient is especially important," he says. "It is especially important for professionals to address minority patients' fears and concerns about tests and treatments."
What To Do
To learn more about the federal government's health insurance program for people 65 and older, visit Medicare.