This biased-doctor model, as we call it, is a woeful misimpression of reality, but one that has become a staple of the health disparities campaign now underway at schools of medicine and in the American Medical Association, the Association of American Medical Schools, and health-care philanthropies.
Peter Bach of Memorial Sloan Kettering Cancer Center and colleagues showed that white and black patients, on average, do not visit the same population of physiciansmaking the idea of preferential treatment by individual doctors a far less compelling explanation for disparities in health. Notably, though, the doctors frequented by black patients were often not in a position to provide optimal care.
Bachs study, which appeared in the New England Journal of Medicine in 2004, found that the vast majority of visits by black patients80 percentwere made to a small group of physicians22 percent of all those in the study. These physicians were less likely to have passed a demanding certification exam in their specialty than the physicians treating white patients. They were more likely to answer not always when asked whether they had access to high-quality colleague-specialists, such as cardiologists or gastroenterologists, to whom they could refer their patients, or to non-emergency hospital services, diagnostic imaging, and ancillary services, such as home health aid.
Along the same lines was a 2002 study by researchers at the Harvard School of Public Health. The study found that physicians working for Medicare managed-care plans in which black patients were heavily enrolled provided lower-quality care to all patients, regardless of race. Specifically, their patients were less likely to receive the four clinical services the authors measuredmammography, eye exam for diabetics, beta-blocker after myocardial infarction, and follow-up after hospitalization for mental illness.
Similarly, a team at the Center for Studying Health System Change in Washington, D.C., assessed the abilities of a random sample of physicians to obtain medically necessary services for their patients. According to the survey, black physicians were more likely to report difficulties admitting patients to hospitals than white physicians, and Hispanic physicians were more likely to report having a poor specialty-referral network than white physicians (is this racism on the part of hospitals?).
The second important factor in treatment disparities is that access to quality care, irrespective of the race of the patient, is tied to geography. With most health care delivered locallyand with racial and ethnic groups not evenly scattered about the countryit is imperative that researchers account for geography in evaluations of health disparities. When they do, they discover that geographic residence often explains race-related differences in treatment better than even income or education.
Consider the effects of location on health disparities in infant mortality rates. Jeannette Rogowski and colleagues at Rand used the rich Vermont-Oxford network dataset to examine the effects of hospital quality on the mortality rates of very low-birthweight babies, controlling for condition of the baby at birth as well as other characteristics such as gestational age, race, method of delivery, birth defects, and prenatal care. The authors found that black and white babies were not delivered at the same kinds of hospitals. Black babies were significantly more likely to be born in government-run hospitals that served a relatively high proportion of Medicaid patients, and where doctors spent less time with patients, mostly due to high patient volume. Further, the hospitals where black babies were born were significantly less likely to have neonatal intensive care units or to perform neonatal cardiac surgery.
Sally Satel M.D. is a resident scholar at the American Enterprise Institute. Jonathan Klick, a health economist and lawyer, is the Jeffrey A. Stoops Professor of Law at Florida State University. The authors just published The Health Disparities Myth: Diagnosing the Treatment Gap.