Yesterday I talked a little about segregation of patients by race in NYC hospitals, and noted how this is likely a problem repeated across the nation. Wonder no more: a 2006 study in the Journal of the American Medical Association (JAMA) analyzed about 719,000 Californians who had received a wide range of complex surgeries. The authors found that blacks, Latinos, and Asians were far less likely to get these operations done at high-volume hospitals, which tend to have better outcomes for complex surgeries. (After all, practice makes perfect).

If you’re white, you’re more likely to receive care at high-volume, better-performing hospitals. This is bad in and of itself; but unfortunately, discrimination continues beyond the level of medical institutions and into the level of individual doctors. A 2004 study in the New England Journal of Medicine looked at the primary care experience of Medicare patients, specifically looking at 150, 391 visits by black and white Medicare beneficiaries for “medical evaluation and management who were seen by 4355 primary care physicians.” Here is what they found:

“Most black patients were confined to a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs.19.3 percent).

The physicians treating black patients also reported facing greater
difficulties in obtaining access for their patients to high-quality
subspecialists, high-quality diagnostic imaging, and nonemergency
admission to the hospital.”

The differential access and care that these studies and others
identify might be called discrimination across health care, i.e.
segregating the pool of patients by race. But even when blacks and
whites find themselves under the same health plan, blacks receive
inferior treatment.

Another 2006 JAMA study
looked at over 400,000 individuals in 151 Medicare health plants
between 2002 and 2004 to judge four outcome measures: (1) control of
glucose and (2) low-density lipoprotein cholesterol (LDL-C) among those
with diabetes, (3) blood pressure control among those hypertension, and
(4) LDL-C control among those who had a acute myocardial infarction or
coronary revascularization procedures.

The study found that clinical performance on these four outcome
measures was “6.8% to 14.4% lower for black enrollees than for white
enrollees” and that “for each measure, more than 70% of this disparity
was due to different outcomes for black and white individuals enrolled
in the same health plan rather than selection of black enrollees into
lower-performing plans.” In other words, black enrollees were getting
worse coverage than white enrollees who shared the same health plan.

As the authors note, this gets us thinking about the discrimination
within care: “our findings…contrast with other recent studies showing
that between-hospital differences are the primary contributor to racial
disparities observed nationally in treatments and outcomes…”

Ultimately the racial inequities of American health care pervade the
system, across hospitals and doctors and even within health plans.
These inequities chip away at the health of our nation, but receive
relatively little institutional focus. Instead, we pat ourselves on the
backs as we synthesize new wonder drugs and build new hospitals
equipped with waterfalls. The U.S. health care system consistently
chooses flashiness over fairness.

The tragedy of this choice was perhaps best described by Steve H.
Woolf, of the Department of Family Practice, Medical College of
Virginia, Fairfax, in an abstract for a 2004 article he wrote in the American Journal of Preventive Medicine:

“Society understands that racial and ethnic minorities experience
inferior medical care and health status, but may not appreciate the
seriousness of the problem.

“Each year the nation spends billions of dollars to perfect the
‘technology of health care (e.g., development of new drugs) and
modernize delivery systems, thereby saving thousands of lives.
Correcting disparities in care, however, would avert five times as many
deaths.

“If policymakers adhered to the goal of optimizing population
health, greater priority would go to resolving disparities than to
refining technology, but reverse priorities prevail…Society has the
resources to enable the disadvantaged to attain better health but
pursues other priorities.”