NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan in Washington.
Not one, but three major studies on racial disparities in health care are out today in the new issue of The New England Journal of Medicine. African-Americans, they conclude, receive inferior care when compared to white people. Another way to summarize the finding is that little has changed since racial disparities in health care came to light more than 10 years ago.
To be fair, there are some bright spots. Medicare narrowed the race gap in most areas, including diabetes and heart conditions, and studies show a dramatic move toward equality when it comes to low-cost treatment, like beta-blockers for cardiovascular problems. But when it comes to pricey procedures like blood vessel repair or back surgery, it's the same old story. And, in several other categories, the gap has widened. For a long time, the black-white health-care gap was attributed to economic differences, but the reasons for disparities appear to be much harder to pinpoint. A 2002 study said that even when all things are equal, there are still major differences in the quality of care.
Later, our final installment of the TOTN movie awards. This time, the big screen's best-ever death scenes. You can still vote: email@example.com.
But, first, persistent disparities in health care. If you're a medical professional, we'd like to hear from you. Do you see differences in health care by race? Why do you think this gap persists? Is it possible that you treat patients differently based on race? Our number here in Washington is (800) 989-8255; that's (800) 989-TALK. And that e-mail address is the same: firstname.lastname@example.org.
We begin with Dr. Nicole Lurie. She's senior natural scientist and professor of health policy at RAND Health, a division of the RAND Corporation, and she's with us from the studios of WSCD in Duluth, Minnesota.
Nice of you to join us today.
Dr. NICOLE LURIE (Professor of Health Policy, RAND Health): Good afternoon.
CONAN: Now you wrote an article in the--this issue of The New England Journal of Medicine called Less Talk, More Action where you argue that we've now had more than enough documentation of this issue and not enough problem-solving. Why does this problem persist?
Dr. LURIE: Well, I think there are lots of reasons why it persists, and I think it's time for us to put our attention toward figuring out what to do about it. If you try to break this down, the first thing I'd want to point out is that there's a difference between disparities in people's health and that in health care. And for today's discussion I think we're probably going to focus on disparities in health care.
Dr. LURIE: For the reasons why it exists, you can start with the fact that people from different racial and ethnic groups have differential access to health insurance, but even health insurance isn't enough. It's necessary but not sufficient. You can say after that there are probably differences in the access to care that they get, both in terms of differences in primary care and in terms of specialty care. It's also well-documented--there are lots of differences in the interaction between patients and doctors, ultimately, ending up in differences in the quality of care that people receive. Even when...
Dr. LURIE: ...quality of care is provided or prescriptions are written or procedures are recommended, what patients--in fact, what their doctors--can access in the community to actually get those needs met often differs as well.
CONAN: Would you say that in this story--and I--another point of clarification, we're talking about African-Americans here. That's what this--these studies go into. Correct? Hispanic Americans may...
Dr. LURIE: We are talking...
CONAN: ...also get less health care, but if so, these studies don't show it.
Dr. LURIE: Right. These articles did deal with African-Americans because that's where it's easy for people to get data or information. But the disparities for Latinos or Hispanic Americans are often quite great as well.
CONAN: OK. Going back, would it be fair to say that there was a whole spate of studies that sort of addressed the situation of `We don't believe this exists,' and now we're so far beyond that that there--one of the fascinating things is you're--these studies seem to show that these disparities continue to exist but there's a survey of doctors, two-thirds of whom say, `No, there's no problem'?
Dr. LURIE: Well, certainly, one of the problems we have is that the general public and doctors, as members of the general public, still are not aware of these. It's probably been only in the past couple of years that this has even begun to reach the public consciousness, and even that is pretty minimal. It's disappointing that most doctors still don't recognize or know that these disparities exist, though.
CONAN: In your article you suggest that at this point, given these persistent patterns, tinkering, changes at the edges--that is not going to make much difference.
Dr. LURIE: Well, I think that's right. There's an old saying in health care that says that the system is perfectly designed to get the results that it does. And what these articles show is over the past decade, year after year after year, the system is getting the same results. In fact, you can probably go back 40 years and find that the system is getting the same results. So that suggests that we're going to need to make major changes in the system if we want major changes in the outcomes.
CONAN: If you'd like to join our conversation, the number is (800) 989-8255. You can also send us e-mail: email@example.com. And let's begin with John. John calls from Detroit in Michigan.
JOHN (Caller): Hello.
CONAN: Hi, John. You're on the air.
JOHN: Oh, thank you for taking my call. I've been a registered nurse for 20 years and I've worked in Michigan, both in an inner-city Detroit hospital, which I do now, and I've worked in a rural northern Michigan hospital, and what I find in the comparison is that--in comparison, there's really no difference in the health care that is provided, or attempted to be provided, in terms of the physicians, the nurses' staffing, the staffs of the hospital. The problem in disparity that I see is not a matter of race; it's a matter of economics. A hospital that is struggling, a hospital that does not have community support does not--has to hold back, cannot get the best physicians, cannot get the best equipment, cannot--the nurse-to-patient ratio is way too high, and I saw this in a small rural northern Michigan hospital where all our patients were white. Same thing. They got--cut corners. They were cutting corners in terms of their care. There were long waits in the ER.
And what I mean by community support, it's only that people are reaping what they sow here. They--community support for a hospital, whether it's public or private, it's a public institution, and it depends on how it's used and how the community supports it. In the Detroit DMC system that I'm presently working, we don't have the insured population like other hospitals do and the people that do have insured population from the community, they don't support that hospital. They drive out to suburban hospitals where they know they don't have to wait so long, where they can get ...(unintelligible).
CONAN: John, excuse me, is what you're saying that whether it's poor whites or poor blacks, poor is the important issue here?
JOHN: Yes, it's economics.
JOHN: Economics. ...(Unintelligible).
CONAN: Let's get a reaction to that from Dr. Lurie.
Dr. LURIE: Well, two points that I would make here. First, is that study after study have shown that while economics plays a role, even after you adjust for economics and the socioeconomic status of the patient, these differences still persist by race. But I think your caller makes another really important point. Other studies have shown, for example, that, in this country, about 80 percent of African-Americans are taken care of by 20 percent of physicians. And when those physicians are surveyed, time after time, they report exactly what the caller reports, that they can't get specialty care for their patients, they can't get high-quality diagnostic care for their patients. It's hard for them to get their patient into a good hospital. It may be because these patients are often coming from distressed areas or maybe, as your caller says, a matter of community support. But that points to one of the major issues in our society that probably contributes to disparities.
CONAN: John, thanks very much; we appreciate it.
JOHN: All right.
CONAN: Let's be--get another voice in on the conversation now. Joining us here in Studio 3A is Dr. Vanessa Northington Gamble. She's director of the Tuskegee University National Center for Bioethics in Research and Health Care.
Good of you to join us today.
Dr. VANESSA NORTHINGTON GAMBLE (Director, Tuskegee University National Center for Bioethics in Research and Health Care): Thank you for having me.
CONAN: And why do you believe that so little has changed despite all these abundance of studies on disparities?
Dr. GAMBLE: I mean, I think Dr. Lurie has pointed out the fact that this is a very complicated multifactoral issue, that--I mean, I think that one of the things we have to--we had to first document, let people know that these disparities do exist. Because...
CONAN: We're not making it up.
Dr. GAMBLE: We're not making it up. Because I--you know, I think there were people who were disparity deniers, that, of course, in America we would not treat people by the color of their skin in terms of health care. So I think we've dealt with that issue. So we've done documentation and I think one of the things that has happened is also we have not been able to get this as part of the political and moral will of the country, that people don't know about disparities. There was a study done several years ago by the Kaiser Family Foundation, and most African-Americans did not know about these disparities in health and health care. And so that I think that we have to get this as part of the body politic.
I think the other thing that--reason why we haven't made a lot of progress--we've made some progress--and I think we really have to be clear; we have made some progress--is that we have focused so much up to this point in documentation that we now need to put our focus on what works, what doesn't work and try to develop strategies so that we're not talking about documenting disparities, but that we really are talking about solutions for the disparities.
CONAN: And let me ask you both about some of the good news that was buried in these studies, and that was Medicaid, which appeared to have narrowed the gap significantly in some important areas, and the thought--and let me ask you, Dr. Lurie, the idea that accountability was an important part of this.
Dr. LURIE: Well, Medicare, and Medicare managed care, in particular, has placed a lot of focus over the last few years on accountability. And by accountability we mean measuring the quality of care explicitly and reporting on the quality of care explicitly. Once you measure it, and it's staring you in the face, you need to do something about it. And beyond that, people are asking you: What are you doing about it? If you're an insurance company, your board is asking you. Employers who purchase from you may be asking you. And patients may be asking you.
CONAN: But are those kinds of statistics kept by insurance companies, hospitals, other institutions?
Dr. LURIE: They are kept, in general, by managed care plans, and many of them go under the rubric of something called HEDIS, which is the Health Employer Data Information Set. It's kind of a mouthful. But every year almost every health plan reports on these measures of quality of care. Now they're limited but they're a report nonetheless. One of the problems, though, is that they report on them for the overall population. And that can mask big differences in different subgroups. By and large...
CONAN: Dr. Northington Gamble, you wanted to get in on this?
Dr. GAMBLE: Yeah, I wanted to say that the other thing is that one of the--these three studies that were in The New England Journal of Medicine show the importance of collecting the data, that we need to have the data and that there are people who believe that it is illegal to collect the data. It is not illegal to collect these data.
CONAN: Data that are divided by race?
Dr. GAMBLE: Race. Race and ethnicity, in terms of health care, and we really need to have those data, and also to have good data. Several years ago I was at a meeting and there was discussion about whites and Native Americans, and they had put the Native Americans in with the white population for the purposes of analyses because there were so few Native Americans. We can't have data like that. Because to put Native Americans and say they're the same as white Americans is very, very flawed.
CONAN: We're going to have to take a short break. When we come back, we're going to continue talking about the gap between the health care for white people and health care for blacks. Why has so little changed over the past 10, even 20 years? (800) 989-8255. E-mail: firstname.lastname@example.org.
I'm Neal Conan. It's TALK OF THE NATION from NPR News.
(Soundbite of music)
CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.
The facts are by this point indisputable. We've known for years now that blacks in America receive inferior medical treatment to whites. But progress over the past decade has been scant at best. That's according to a number of reports out today in The New England Journal of Medicine. There has been little improvement in bridging the gap in most areas, and in some aspects of health care, the gap has grown. If you or a family member has been impacted by the disparity, if you're a provider, perhaps an African-American doctor or nurse, what is your perspective? (800) 989-8255; (800) 989-TALK. E-mail us: email@example.com.
Our guests are Dr. Nicole Lurie, a senior natural scientist and professor of health policy at the RAND Corporation, and Dr. Vanessa Northington Gamble, the director of Tuskegee University's National Center for Bioethics in Research and Health Care. And let's get another caller on the line now. This is George. George calling from Glendale, Arizona.
GEORGE (Caller): Yes, thank you for taking my call.
GEORGE: I have--I'm--I treat people with orthopedic problems and I know firsthand that, for example, when I was in my senior year of training--when I was treating--and I'm a black physician. When I was treating a black patient, and I spent the time necessary, you know, sometimes requiring a bit more time, I was hurried along, `OK,' you know, `You have to get going. You have to get things going. Let's not spend too much time here.' But if I spent the same level of care with a white person, `Oh, Dr. Thompson(ph), you know, you're doing very well, you're doing very well. Just--you're doing a very good job.' I know that when I graduated, they--there was a very thick book, and you go in there and that--and--'cause you have to know, you know, when you apply for residency, you go for the match. You know what institutions accept blacks. You know what institutions accept women, which institutions accept Jews. And things really haven't changed very much at all.
CONAN: Can I ask when you graduated medical school?
GEORGE: And it's--and the racism is very clear where if you are black, if you are Hispanic, you know, you're considered less--your illness is of less value than white people's. And so to spend the time, to spend the effort to get that MRI, to get that extra--that other study, the--you--it's--throws up a red flag more quickly than with a white person.
CONAN: Let's get responses to that. Dr. Lurie.
Dr. LURIE: Well, certainly, lots of patients and lots of doctors report these kinds of experiences. We know that there are differences in the amount of time spent with patients. We know that there are differences in the quality of the interaction. And the quality of the interaction isn't just something really abstract. We know, for example, if patients are felt as though they're not treated with respect, that they're less likely to follow up, or they're less likely to take their medicines. And so spending time with people, explaining things to them makes all the difference in the world in what's going to happen to the patient at the other end. I spent a long time in medical education, training medical students and residents, and I, too, would say very often that medical students or residents from different minority groups have a higher hill to climb. They have to prove something. They have to prove their worth where sometimes other doctors didn't have to.
CONAN: Dr. Gamble, let me ask you, is--are doctors the problem here?
Dr. GAMBLE: I think that there are several problems here. And I think that we can't just say, `Are doctors the problem?' We have a system where people might not have access to care. There's a transportation system where they can't get to the hospital or they're not treated with respect. So we have several problems here, but we--doctors are part of the problem. And hearing George talk, being an African-American physician myself, and Dr. Lurie and I went to medical school together, and we--she saw some of the things that I, as an African-American woman, had to face, that one of the things we have to be able to do is have the conversation with physicians and also other health-care providers--so physicians aren't the only health-care providers--about issues of race and racism in the system without people thinking once you get a white coat, somehow that erases your racism.
CONAN: George, thank you very much for the phone call.
GEORGE: One more thing I was saying, it is the institution I'm talking about, not the doctors. It is the institution. Like, for example, the hospital, for example. This experience that I had where--had actually in the VA hospitals, mainly, I'm referring to. And this is the paying system, for example, with the managed care system, that it's set up so that minorities don't get the same level of care 'cause it's not really being paid for. And that's what--that's the greater issue. It's certainly not the dedication of physicians, per se. It is the way black physicians are required to treat minorities vs. white physicians and the white physicians or the white training physicians will try to hurry us along when it comes to minorities vs. when it's whites.
CONAN: Doctor--George, thanks very much. Appreciate it.
GEORGE: You bet.
CONAN: OK. Joining us now is Dr. Chuck Cutler. He's national medical director for quality at Aetna, which is a large national health provider, and he's with us by phone from his office in Chicago.
Nice to talk to you today.
Dr. CHUCK CUTLER (National Medical Director for Quality, Aetna): Thank you; nice to join you.
CONAN: A couple of years ago Aetna began collecting information about its members' racial backgrounds. How come?
Dr. CUTLER: Well, as your previous speaker has pointed out, we know that there are disparities in health care between various racial and ethnic groups, and we thought by collecting this kind of information, there are things that we could do to try to address some of those disparities.
CONAN: And how did that information prove to be useful?
Dr. CUTLER: Well, the information has proved to be useful in exactly the way that one might expect, which is we know that certain problems occur more frequently with certain racial and ethnic groups. For example, African-Americans have a much higher risk of prenatal problems and problem deliveries. So by being able to identify any African-American woman who's pregnant, we can automatically enter them into a high-risk pregnancy program, get them the kind of additional services they need to avoid those kinds of prenatal problems and high-risk pregnancies. We can also do outreach to women who are not getting the kinds of preventative screening that they should. Again, you know, African-American women are more at risk for breast cancer and we've been able to develop programs to reach out to African-American and Latino women using African-American women and people who speak Spanish in order to increase mammography screening.
CONAN: Did the act of gathering this information and discovering what it said--did the act of gathering that information in and of itself change the way Aetna treated these disparity issues?
Dr. CUTLER: Well, in addition to collecting this information, we've done a number of things that the previous speakers have said that the health-care system as a whole should do. We introduced a cultural competency training program for all of our medical professionals; that's over a thousand medical professionals on the Aetna staff. So in addition to collecting the information, which we thought was an important statement about Aetna's approach toward addressing disparities, we felt we needed to provide the training for our medical professionals to understand how best to address the disparities. The challenge, as the previous speakers have pointed out, is not that we identify that the disparities exist, but what is it that we should do about them?
So one of the things we've been able to do is by identifying disparities in our own population, we've begun research in identifying what is it that caused the disparities and then what is it that we as a health plan could do to try to decrease them.
CONAN: But one of--our guests are also suggesting that data collection is in and of itself an important factor. As you looked at this data, has it--have the gaps narrowed over the time since Aetna began gathering the data?
Dr. CUTLER: Well, it's too early to tell that because we've only been gathering the data for about two and a half years, and, at this point, we have about two and a half million people who've given us that information. That's increased over that period of time. What I can tell you is that we've found some surprises which is early on we did a preliminary analysis, and I say that because it was small numbers, but we found that there were not disparities in areas that one might have expected. For example, we didn't find significant disparities in the use of anti-hypertensive medicines between African-Americans and whites, or in some other measures where we thought there might be disparities. On the other hand, we did find and confirm some of the disparities that others have found in terms of control of diabetes, for example. So in the population that we serve, which are people who are employed, who have health insurance, not all the disparities which have been previously pointed out in the literature exist.
CONAN: But that--as you pointed out, that's an important subset of the population there.
Dr. CUTLER: Absolutely.
Dr. CUTLER: Absolutely.
CONAN: Aetna's initiative was regarded as highly unusual for such a large national carrier. How come?
Dr. CUTLER: Well, our leader, our chairman, is a physician who's--had been a professor of medicine, and who felt strongly that Aetna could play a role in eliminating the disparities, or at least decreasing the disparities. He knew the disparities that existed and felt that, as a health plan, the kinds of activities that we could do, in terms of outreach, in terms of helping people understand their disease, and in terms of developing programs specifically targeted to populations with a cultural bent in mind, are things that we could do, as a plan, that would have a very positive effect on the population that we serve.
CONAN: Dr. Cutler, thanks very much for being with us today.
Dr. CUTLER: You're welcome; thank you.
CONAN: Chuck Cutler is national medical director for quality at Aetna and joined us by phone from his office in Chicago.
Let's get another caller on the line, and this is Sharon. Sharon calling from Little Rock, Arkansas.
SHARON (Caller): Yes. Hi.
CONAN: Hi. You're on the air.
SHARON: Hi. How are you?
CONAN: I'm very well; go ahead, please.
SHARON: Well, I am an advanced practice nurse and I work in pediatric neurology, which is a very tough specialty group, and the patients that I see--I have known for a long time about the disparity in health care and the patients that I see, the patient population that I follow, primarily have epilepsy and other neurological disorders, tics, Tourette's, that type of thing. But because there are so few people who look like me, I wanted to make sure that those patients who see me know that I'm there to answer any questions. I try to spend as much time with them to try and dispar--or try and resolve, if at all possible, the disparity in the care that they may have been receiving in the past. But I think that it's important for there to be people who look like us providing care to all patients. And I also try to make sure that it's not a discrepancy between the patients that I see.
CONAN: That's an important point, Sharon. And let me ask Dr. Lurie about that. Ten years ago and more, when these problems first began to surface in a documented way, people said, `Well, if we get more African-American nurses and doctors out there, the problem will self-correct.'
Dr. LURIE: And I think since that time, if not before, people have been trying to get more African-American doctors and nurses out there, and, time after time, unfortunately, we've still fallen short of our goals, another way, I guess, in which the system is designed so far to get the results that it does. There are some suggestions that sometimes having a match between the patient's race and ethnicity and the doctor's leads to better--or is associated with better communication or better outcomes, and other data suggest that that doesn't really matter as much as how good the communication is, whether the doctor of nurse explains to the patient and the patient's family what's going on, whether they treat them with respect, etc.
CONAN: Sharon, thank you very much for the call.
SHARON: Thank you.
CONAN: We are talking with--well, you just heard Dr. Nicole Lurie of the RAND Corporation, and we're also speaking with Dr. Vanessa Worthington Gamble of the Tuskegee University National Center for Bioethics in Research and Health Care. You're listening to TALK OF THE NATION, which is coming to you from NPR News.
And let's get another caller on the line before we go, and this is Doris, Doris calling from Nashville, Tennessee.
DORIS (Caller): Hi. Yes. I'm calling. Dr. Gamble, I'm an old student of yours from the University of Wisconsin. Hello.
Dr. GAMBLE: Hello.
DORIS: I just want to say, as both an African-American woman who is in emergency medicine...
(Soundbite of baby screaming)
DORIS: Sorry, my seventh-month-old is...
CONAN: I was going to say, `and a mother.' Yes.
(Soundbite of laughter)
DORIS: And a mother, yes. That there--I see disparities both--on two ends, one as a practitioner coming who is board certified, fully competent. The places where I've had my employment, just being accepted as a colleague has been a little bit more difficult for me, as accepted--as somebody who is definitely competent to practice medicine at these institutions vs. my other white counterparts. And then on the flip side, in the emergency department...
(Soundbite of baby screaming)
DORIS: ...I definitely see disparities based on race because of just old stereotypes. For instance, when we have trauma patients who come into the department--I mean, a lot of times, patients, depending on what kind of trauma was their issue at the time--a lot of doctors may or may not institute, you know, pain medicine right away or they may think that, `Oh, well, the reason why this patient was hurt--because they were in a gang or they are up to illegal type of activities and things like that...'
CONAN: Somehow it was their own fault. Yeah.
DORIS: Right, it was their own fault. And so you see, definitely, how much a lot of times doctors go through to explain emergency procedures and techniques to patients that they may need right away. I've seen, you know, doctors who I work with as well as surgeons, trauma surgeons, who, you know, may explain to a white male that the reason why they need an operation is because, you know, they may be bleeding internally, vs. a black male, where I've seen them say, `Well, you need an operation right now or else you could die.' And I just think that old stereotypes that people bring with them, their experiences from their childhood or even adulthood--when becoming physicians, they bring that with them when they practice medicine.
CONAN: Dr. Gamble, what would you say to your former student?
Dr. GAMBLE: And, Doris, you should say also you are a Tuskegee alum.
DORIS: That is correct.
Dr. GAMBLE: (Laughs) Had to put that in there. But I think Doris brings up a critical point, that by the time people get to medical schools, they have been socialized into the racial attitudes of the society. Years ago at Wisconsin, I used to do an exercise where I would ask students--and these were undergraduate students who were interested in medicine--to tell me stereotypes about African-Americans, and I would say positive and negative stereotypes. They were all negatives. They were stereotypes about black people are more violent, and that comes up with the examples that Doris brought up in the emergency room. They were more promiscuous, that if a black woman comes into an emergency department with pelvic--with abdominal pain, that it's a sexually transmitted disease first, before--with a white person you might not think that.
So people do bring these stereotypes. What brings up the critical issue--I firmly believe--and I've spent most of my life trying to increase the number of minorities in the medical profession. But at the same time, we cannot let white physicians off the hook in terms of issues around cultural competence, in terms of understanding the baggage, the personal baggage that they bring to the system, so that we have to, one, I think, increase the number of minorities, but at the same time have programs to--in cultural confidence and other areas to improve the skill sets of white physicians.
CONAN: Dr. Lurie, we just have a few seconds left, and I'm sorry to put you on the spot like this, but if there was another set of these studies in two years in the New England Journal of Medicine, would you expect to see much change?
Dr. LURIE: What I would really like to see in two years in the New England Journal of Medicine is a set of studies in which people describe the kinds of things they tried to make them better and whether or not they worked. I'd love to see people like Chuck Cutler write an article about what their experience has been as they've tried to implement interventions at Aetna and all of the other places that are trying to do the same kinds of things.
CONAN: Well, let me thank you all for participating. First, Doris, thank you very much for the call.
DORIS: Thank you.
CONAN: And--appreciate that. Dr. Nicole Lurie joined us from WSCD in Duluth, Minnesota, senior natural scientist and Paul O'Neill Alcoa Professor of Health Policy at RAND. Thank you very much.
Dr. LURIE: Thank you.
CONAN: And Dr. Vanessa Northington Gamble, director of Tuskegee University's National Center for Bioethics, thank you very much.
Dr. GAMBLE: Thank you.
CONAN: When we come back from a short break, it's the TALK OF THE NATION movie awards: best death scene ever. This is TALK OF THE NATION from NPR News.
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