What are Physicians What
are Physicians
Doing to Address Racial and Ethnic Disparities?
Jim Reschovsky, Ellyn Boukus &
Claire Gibbons
2009 Academy Health Annual Research Conference, Chicago Illinois
Background
• Racial/Ethnic disparities in health care prevalent and overall not improving (AHRQ Disparities Report)
• Underlying reasons multifaceted, but provider bias, Underlying reasons multifaceted but provider bias
uncertainty, and stereotyping all contribute.
Several organizations have identified specific actions
• Several organizations have identified specific actions physicians and their practices should take in order to improve minority health
– 2003 IOM report; 2009 MGH guidelines; 2009 NQF recommendations Objective & Data
Objective & Data
• Objective: to gauge adoption of specific measures to improve treatment of minorities among patient care physicians nationally
patient care physicians nationally
• Data: 2008 HSC Health Tracking Physician Survey
–N
Nationally representative of non‐federal physicians i
ll
i
f
f d l h i i
who provide more than 20 hours of direct patient care weekly
– N=4,720
– Mail survey
– Response rate=62%
Response rate=62%
Recommendations
• P
Provide interpreter services when needed
id i t
t
i
h
d d
• Provide patient information materials in foreign languages
g g
• Promote provider training on minority health issues (e.g., cultural competency)
• Use information systems to:
Use information systems to:
– Report patient preferred language
– Generate data on patient demographics
– Generate reports on the quality of care provided to patients in different R/E groups.
• Employ care management practices, generally.
p y
g
p
,g
y
Adoption of Recommended Measures Low
Percent of physicians
23
Provides Interpretation (Sing. Lang.)
30
Provides Interpretation (Mult. Lang.)
39
Pt. Ed. Matierials in Foreign Lang.
40
Rec'd Trng. In Minority Health
16
Infor Syst. Provides Preferred Lang.
23
Info. Syst. Provides Patient Demog.
12
Quality Reports by R/E grp.
0
All Physicians
10
20
Low Min. Practice (<10%)
30
40
50
60
Maj. Minority pract.
70
Interpretation Services Not Assoc.
with Fewer Communication Difficulties
ih
i i
iffi l i
% pts phys. has difficulty
difficulty communicating with b/c diff. Languages spoken
No interpretation provided (
(43%)
)
Provides interpret. in 1 language (23%)
g g
Reported pt. communication difficulties b/c lang /cult Differences
lang./cult. Differences a major problem
Provides interpret. In 2 languages (9%)
Provides interpret. In 3+ languages (13%)
Unable to obtain interpret. services in
interpret. services in pst. yr.
Provides translator Provides
translator
services (telephonic) (8%)
0
10
20
30
Notes: Does not include 4% of physicians with no non‐English speaking patients
Adjusted for percent of minority patients in practice panel
Adoption of Measures Generally Low
y
Percent of physicians
23
Provides Interpretation (Sing. Lang.)
30
Provides Interpretation (Mult. Lang.)
39
Pt. Ed. Matierials in Foreign Lang.
40
Rec'd Trng. In Minority Health
16
Info. Syst. Provides Preferred Lang.
23
Info. Syst. Provides Patient Demog.
12
Quality Reports by R/E grp.
0
All Physicians
10
20
Low Min. Practice (<10%)
30
40
50
60
Maj. Minority pract.
70
Adoption of Measures Varies Strongly with Practice Type & Size
gy
yp
% All Phys.
(col %)
All Physicians
All Physicians
Mean % Min. Pts.
Composite Score
p
Low (0‐2)
Medium (3‐4)
High (5‐6)
100%
32 5
32.5
52%
37%
11%
Solo/2 phys.
33
30
65
27
7
Sm. Group (<=10)
23
27
65
30
5
Lg. Group (>10)
15
30
50
40
9
G/S HMO
4
36
10
42
48
CHC
3
53
26
56
18
Hosp./Med
/ d School
h l
21
40
28
55
17
Other
1
39
46
47
7
Practice Type
Few Other Associations
Few Other Associations
• Little
Little variation in adoption among PCPs, variation in adoption among PCPs
medical specialists and surgical specialists
• Greater adoption in urban areas (reflects avg. Greater adoption in urban areas (reflects avg
practice size/type, % minority)
• Minority physicians (who treat more Mi i
h i i
( h
minorities) more likely to adopt measures
• Scant difference across physician demographics
Adoption Of Measures To Address Di
Disparities, By Percent Minority Pts.
ii B P
Mi i P
Percent Minority P i
Patients
(Col. %)
Row Percent
Row Percent
(% minority pts.):
Low: <10% 18% (2%)
Medium : 10‐50%
62% (50%)
62% (50%)
High: >50%
21% (48%)
Composite Score
Low (0‐2)
Medium (3‐4)
High (5‐6)
52% (44%)
(
)
37% (42%)
(
)
11% (14%)
(
)
11 (1)
11 (1)
5 (1)
5 (1)
1 (0)
1 (0)
34 (27)
22 (18)
6 (5)
7 (16)
10 (23)
4 (9)
Note: Numbers in dark blue section are % of all physicians. (They sum to 100_ Numbers in parentheses are weighted by each physician’s percent minority patients—a crude measure of exposure of minority patients to physicians.
Summary
• Ph
Physician efforts to adopt measures to address R/E i i
ff t t d t
t dd
R/E
disparities low to moderate
– Adoption of measures associated with cost of implementation and legal requirements
• Adoption strongly associated with practice size and yp
type
– Solo and small groups fare worst
– G/S HMOs & large institutional practices perform best.
• Adoption
Adoption associated with % minorities in patient panel
associated with % minorities in patient panel
• Adoption does not guarantee physician behavior affected
Policy Implications
Policy Implications
• Many
Many practices lack resources & technical know‐how practices lack resources & technical know‐how
to implement care management/HIT systems
– HIT incentives in stimulus package will help
p
g
p
• Movement of physicians to larger organizations p
probably beneficial
y
– Health reform likely to speed that transition
• Legal requirements for provision of interpreter services should be clarified. Policy Implications (con’t.)
Policy Implications (con
t.)
• Policies should be directed to adoption of measures in (especially in solo/small group practices)
– Majority of care provided to minorities takes place in these g
settings
– State regulatory agencies and professional societies (via board recertification) could require adoption of low‐cost measures:
• Patient education materials
• Cultural competency training
• More expensive measures (e.g., HIT or telephonic p
( g,
p
interpreter services) appropriate for public subsidy
• With limited resources, target high‐minority practices.