Medical Care Lacking but Equal
Thursday, March 16, 2006
Blacks and Hispanics tend to receive slightly better day-to-day medical care than whites when they see a doctor, a large and surprising study has found, sparking new debate about the impact of race on health in America.
The study, the most comprehensive examination of the quality of primary care in the United States, found no significant differences among patients from different ethnic groups or incomes once they get to see a doctor, but a slight trend toward better care for blacks and Hispanics.
The researchers stressed, however, that other disparities in health care do exist. Poor people and minorities, for example, are less likely to see a doctor in the first place and they receive far less expensive care. In addition, the minor variations among racial groups found in the study are swamped by the low level of care everyone gets, they said.
"The bottom line of this study is patients are getting about half of recommended care, and it doesn't seem to matter where you live, whether you are white, black or Hispanic, are insured or uninsured," said Steven M. Asch, who helped conduct the study for the Rand Corp. "Everyone is at equal risk for poor quality of care."
But the findings, published in today's New England Journal of Medicine, startled researchers because they appeared to run contrary to a large body of evidence that poor people and minorities tend to receive worse care than whites in all areas of health care, a disparity often cited to explain why their health tends to be worse and life spans shorter.
"So many previous studies have shown disparities," Asch said. "In that way, it is surprising. We looked in as many ways as we could to try to determine if there was a problem with our analysis. I'm convinced that's not the case."
Skeptics of the significance of discrimination in health care immediately pointed to the findings to support their view that the focus on race has been misplaced.
"The obsession with racial disparities is a distraction from what we really need to do, which is improve health care for everyone," said Sally Satel, who studies health care at the American Enterprise Institute, a conservative think tank. "This shows us that, if anything, minority groups actually have even somewhat better outcomes."
But Asch and other experts said there is clear evidence from many other studies that racial disparities persist in important aspects of health care that the new study did not examine.
The new study focused broadly on routine care, such as whether heart patients are told to take aspirin, whether women have mammograms and whether diabetics have their blood sugar tested regularly. Earlier studies examined particular aspects of the system, such as access to care, or particular procedures, such as heart-bypass surgery and kidney dialysis.
In those areas, "disparities still exist, there's no question," said Joseph Betancourt of Massachusetts General Hospital in Boston. "We need to continue to push and address those disparities, which we know are alive and well."
Ashish Jha of the Harvard School of Public Health said: "We see the biggest difference when we look at more complex things like heart-bypass surgery and how well patients do in the long term. There's no question those disparities are important. What this study says is for simpler things in health care, the differences are really much smaller."
Asch and his colleagues analyzed data collected through telephone interviews and medical records from a nationally representative sample of 6,712 adults living in 12 communities nationwide between 1998 and 2000. (None were in the Washington area.) Using 439 widely accepted criteria to evaluate the care they received for 30 common chronic and acute medical conditions and for disease prevention, the researchers determined that overall, people received just 54.9 percent of the appropriate care.
When the researchers examined quality across various socioeconomic groups, they were surprised to find that there was little variation, and that racial minorities and poor people received slightly better care overall. Blacks received 57.6 percent of recommended care, Hispanics received 57.5 percent and whites received 54.1 percent.
"We know African Americans and poor people are less likely to get in the door of the system. And we also know that poor people and African Americans have worse health than white people. What this shows is those differences appear not to be due to the bread-and-butter medical care they receive," Asch said.
He said the study did not examine why minorities might receive better care, stressing that the most important finding was the overall low level of care everyone receives.
"Those small differences are really insignificant compared to the overall low level of care," he said.
In addition, there are other clear differences between racial groups that probably influence health, such as environmental exposures and whether patients follow doctors' instructions, Asch said.
Other researchers agreed but said the findings indicate that quantity of care may be less important than quality. The findings support the idea that efforts to improve care should focus on increasing quality for everyone, not equalizing care between races.
"Just because you see disparities doesn't mean that everyone should be getting more care. Maybe they should be getting less care. There's a big question about overuse," said Amitabh Chandra of Harvard's John F. Kennedy School of Government. "It may not be what's being done but whether you are being treated by a high-quality physician."
Other researchers said the findings may be skewed because the study may have missed the poorest people -- those who do not have telephones or never see a doctor.
"I wouldn't use this to generalize either by economic or race and ethnicity," said David Williams of the University of Michigan. "This data is not consistent with lots of data we have on a national basis."