4. STUDY CHARGE  Assess the extent of racial and ethnic differences in healthcare that are not otherwise attributable to known factors such as access to care (e.g., ability to pay or insurance coverage);  Evaluate potential sources of racial and ethnic disparities in healthcare, including the role of bias, discrimination, and stereotyping at the individual (provider and patient), institutional, and health system levels; and,  Provide recommendations regarding interventions to eliminate healthcare disparities.

5. Access (e.g., insurance status, ability to pay for healthcare) is the most important predictor of the quality of healthcare across racial and ethnic groups Access (e.g., insurance status, ability to pay for healthcare) is the most important predictor of the quality of healthcare across racial and ethnic groups It is difficult – even artificial – to separate access- related factors from social categories such as race and ethnicity It is difficult – even artificial – to separate access- related factors from social categories such as race and ethnicity The bulk of research on healthcare disparities has focused on black-white differences – more research is needed to understand disparities among other racial and ethnic minority groups The bulk of research on healthcare disparities has focused on black-white differences – more research is needed to understand disparities among other racial and ethnic minority groups CAVEATS

6. Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Quality of Health Care Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care Populations with Equal Access to Health Care

7. Evidence of Racial and Ethnic Disparities in Healthcare Disparities consistently found across a wide range of disease areas and clinical services Disparities consistently found across a wide range of disease areas and clinical services Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc. Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc. Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995) Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)

8. Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et al., JAMA, March 13, 2002)

9. Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993

10. What are potential sources of disparities in care? Health systems-level factors – financing, structure of care; cultural and linguistic barriers Health systems-level factors – financing, structure of care; cultural and linguistic barriers Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences Disparities arising from the clinical encounter Disparities arising from the clinical encounter

11. Potential Sources of Racial and Ethnic Healthcare Disparities – Healthcare Systems-level Factors Cultural and linguistic barriers – many non- English speaking patients report having difficulty accessing appropriate translation services Cultural and linguistic barriers – many non- English speaking patients report having difficulty accessing appropriate translation services Lack of stable relationships with primary care providers – minority patients, even when insured at the same level as whites, are more likely to receive care in emergency rooms and have less access to private physicians Lack of stable relationships with primary care providers – minority patients, even when insured at the same level as whites, are more likely to receive care in emergency rooms and have less access to private physicians Financial incentives to limit services – may disproportionately and negatively affect minorities Financial incentives to limit services – may disproportionately and negatively affect minorities “Fragmentation” of healthcare financing and delivery “Fragmentation” of healthcare financing and delivery

12. Potential Sources of Racial and Ethnic Healthcare Disparities – Patient-level Factors Minority patients may be more likely to refuse recommended services, adhere poorly to treatment, and delay seeking care Minority patients may be more likely to refuse recommended services, adhere poorly to treatment, and delay seeking care These may develop as a result of poor cultural match between patients and providers, misunderstanding of provider instructions, poor prior interactions with health care systems, lack of knowledge of how to best use services These may develop as a result of poor cultural match between patients and providers, misunderstanding of provider instructions, poor prior interactions with health care systems, lack of knowledge of how to best use services Patient level factors unlikely to be major sources of healthcare disparities Patient level factors unlikely to be major sources of healthcare disparities

13. Potential Sources of Racial and Ethnic Healthcare Disparities - Disparities arising from the clinical encounter The Core Paradox: How could well-meaning and highly educated health professionals, working in their usual circumstances with diverse populations of patients, create a pattern of care that appears to be discriminatory?

14. Disparities in the Clinical Encounter: The Core Paradox Possibilities examined: bias (prejudice), uncertainty, stereotyping Bias – no evidence suggests that providers are more likely than the general public to express biases, but some evidence suggests that unconscious biases may exist Bias – no evidence suggests that providers are more likely than the general public to express biases, but some evidence suggests that unconscious biases may exist Uncertainty – a plausible hypothesis, particularly when providers treat patients that are dissimilar in cultural or linguistic background Uncertainty – a plausible hypothesis, particularly when providers treat patients that are dissimilar in cultural or linguistic background Stereotyping – evidence suggests that providers, like everyone else, use these ‘cognitive shortcuts’ Stereotyping – evidence suggests that providers, like everyone else, use these ‘cognitive shortcuts’

15. Disparities in the Clinical Encounter Stereotyping: A Definition Stereotyping can be defined as the process by which people use social categories (e.g. race, sex) in acquiring, processing, and recalling information about others. Stereotyping beliefs may serve important functions - organizing and simplifying complex situations and giving people greater confidence in their ability to understand, predict, and potentially control situations and people.

16. Disparities in the Clinical Encounter Stereotyping: Risks Can exert powerful effects on thinking and actions at an implicit, unconscious level, even among well-meaning, well-educated persons who are not overtly biased. Can exert powerful effects on thinking and actions at an implicit, unconscious level, even among well-meaning, well-educated persons who are not overtly biased. Can influence how information is processed and recalled. Can influence how information is processed and recalled. Can exert “self-fulfilling” effects, as patients’ behavior may be affected by providers’ overt or subtle attitudes and behaviors. Can exert “self-fulfilling” effects, as patients’ behavior may be affected by providers’ overt or subtle attitudes and behaviors.

17. Disparities in the Clinical Encounter Stereotyping: When Is It in Action? Situations characterized by time pressure, resource constraints, and high cognitive demand promote stereotyping due to the need for cognitive ‘shortcuts’ and lack of full information.

18. What is the Evidence that Physician Biases and Stereotypes May Influence the Clinical Encounter? van Ryn and Burke (2000) - study conducted in actual clinical settings found that doctors are more likely to ascribe negative racial stereotypes to their minority patients. These stereotypes were ascribed to patients even when differences in minority and non-minority patients’ education, income, and personality characteristics were considered. van Ryn and Burke (2000) - study conducted in actual clinical settings found that doctors are more likely to ascribe negative racial stereotypes to their minority patients. These stereotypes were ascribed to patients even when differences in minority and non-minority patients’ education, income, and personality characteristics were considered. Finucane and Carrese (1990) - Physicians more likely to make negative comments when discussing minority patients’ cases. Finucane and Carrese (1990) - Physicians more likely to make negative comments when discussing minority patients’ cases.

19. What is the Evidence that Physician Biases and Stereotypes may Influence the Clinical Encounter (cont’d)? Rathore et al. (2000) – found that medical students were more likely to evaluate a white male “patient” with symptoms of cardiac disease as having “definite” or “probable” angina, relative to a black female “patient” with objectively similar symptoms. Rathore et al. (2000) – found that medical students were more likely to evaluate a white male “patient” with symptoms of cardiac disease as having “definite” or “probable” angina, relative to a black female “patient” with objectively similar symptoms. Abreu (1999) – found that mental health professionals and trainees were more likely to evaluate a hypothetical patient more negatively after being “primed” with words associated with African American stereotypes. Abreu (1999) – found that mental health professionals and trainees were more likely to evaluate a hypothetical patient more negatively after being “primed” with words associated with African American stereotypes.

20. SUMMARY OF FINDINGS  Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable.  Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life.  Many sources – including health systems, health care providers, patients, and utilization managers– contribute to racial and ethnic disparities in health care.  Many sources – including health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care.

21. SUMMARY OF FINDINGS (Continued)  Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.  Racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences in refusal rates are generally small, and minority patient refusal does not fully explain healthcare disparities.

22. SUMMARY OF RECOMMENDATIONS GENERAL RECOMMENDATION Increase awareness of racial and ethnic disparities in health care among the general public and key stakeholders, and increase health care providers’ awareness of disparities.

23. LEGAL, REGULATORY, AND POLICY RECOMMENDATIONS  Avoid fragmentation of health plans along socioeconomic lines, and take measures to strengthen the stability of patient-provider relationships in publicly funded health plans;  Increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals;  Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees;  Provide greater resources to the U.S. DHHS Office of Civil Rights to enforce civil rights laws.

24. HEALTH SYSTEMS INTERVENTIONS HEALTH SYSTEMS INTERVENTIONS  Promote the consistency and equity of care through the use of evidence-based guidelines;  Structure payment systems to ensure an adequate supply of services to minority patients, and limit provider incentives that may promote disparities;  Enhance patient-provider communication and trust by providing financial incentives for practices that reduce barriers and encourage evidence-based practice;  Promote the use of interpretation services where community need exists. The use of community health workers and multidisciplinary treatment and preventive care teams should also be supported.

25. EDUCATION  Patient education programs should be implemented to increase patients’ knowledge of how to best access care and participate in treatment decisions.  Integrate cross-cultural education into the training of all current and future health professionals.

26. DATA COLLECTION AND MONITORING  Collect and report data on health care access and utilization by patients’ race, ethnicity, socioeconomic status, and where possible, primary language;  Include measures of racial and ethnic disparities in performance measurement;  Monitor progress toward the elimination of health care disparities;  Report racial and ethnic data by OMB categories, but use subpopulation groups where possible.

27. NEEDED RESEARCH  Conduct further research to identify sources of racial and ethnic disparities and assess promising intervention strategies, and;  Conduct research on ethical issues and other barriers to eliminating disparities.