Potential Sources of Racial and Ethnic
Healthcare Disparities – Healthcare Systemslevel Factors
Cultural and linguistic barriers – many nonEnglish 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

Financial incentives to limit services – may
disproportionately and negatively affect minorities

“Fragmentation” of healthcare financing and
delivery

Disparities in 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?
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
 Uncertainty – a plausible hypothesis, particularly
when providers treat patients that are dissimilar
in cultural or linguistic background
 Stereotyping – evidence suggests that
physicians, like everyone else, use these
‘cognitive shortcuts’
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.
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 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.
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.
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.
Finucane
and Carrese (1990) - Physicians more
likely to make negative comments when
discussing minority patients’ cases.
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.
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.
“Patients” experiencing symptoms of heart
disease, from Schulman et al. (1999)
“Patients” experiencing symptoms of heart
disease, from Schulman et al. (1999)
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.
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. While indirect evidence from several
lines of research supports this statement, a greater
understanding of the prevalence and influence of
these processes is needed and should be sought
through research.
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.
SUMMARY OF RECOMMENDATIONS
GENERAL RECOMMENDATIONS
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.
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;
LEGAL, REGULATORY, AND POLICY
RECOMMENDATIONS (Continued)
Increase in 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.
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.
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.
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.
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.