Racial Disparity in Health Outcomes Despite Quality Care

Even when enrolled in identical Medicare health plans, black patients have worse health outcomes than white patients.

The finding comes from researchers at Harvard and Brown universities, who studied data from 431,573 patient visits covered by 151 Medicare managed care plans from 2002 to 2004.

In an earlier study of Americans enrolled in managed care plans, researchers Amal N. Trivedi, MD, MPH; John Z. Ayanian, MD; and colleagues found encouraging data. In managed care plans, they found, the quality of care given to black patients was rapidly becoming as good as the quality of care given to white patients.

Unfortunately, the new findings burst that bubble. Regardless of whether they are enrolled in high-quality or low-quality Medicare managed care plans, black patients don't benefit as much as white patients.

"We found no differences in racial disparity between lower- and higher-quality plans," Ayanian tells WebMD. "It is not simply that African-Americans enroll more often in low-quality plans. We found that over two-thirds of the disparity in outcomes was evident across health plans."

The findings appear in the Oct. 25 issue of The Journal of the American Medical Association.

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Poorer Diabetes, Heart-Disease Control for Blacks

Ayanian and colleagues looked at three important things patients should get from health care:

--People with diabetes should be able to get their high blood sugar under control.

--People with high blood pressure should be able to lower it.

--People with high cholesterol should be able to lower their cholesterol -- especially if they have diabetes or if they've already had a heart attack.

Across 151 health plans studied:

--Among patients with diabetes, 80.2 percent of whites and 72.2 percent of blacks got their blood sugar under control.

--Among patients with high blood pressure, 60.2 percent of whites and 53.4 percent of blacks got their blood pressure under control.

--Among patients with diabetes, 72.2 percent of whites and 62.9 percent of blacks got their cholesterol under control.

--Among patients who had had previous heart attacks, 71.6 percent of whites and 57.2 percent of blacks got their cholesterol under control.

In the best health care plans, more than half of patients improve on all these measures. In the worst plans, fewer than half improve.

The high-quality plans and low-quality plans all enrolled both black and white patients. Racial disparities were just as common in the high-quality plans as in the low-quality ones.

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More Than Doctors Alone Can Fix

This is no surprise to Thomas A. LaVeist, PhD, director of the Center for Health Disparities Solutions at Johns Hopkins University's Bloomberg School of Public Health.

"These are people who had insurance, got care, were seen in the system -- and got different outcomes according to race," LaVeist tells WebMD. "So all the excuses we hear -- that it is lack of insurance, that it is patient preference that drives disparity -- are out of the question."

Why is racial disparity in health care so hard to get rid of?

"At the core here, we have a problem in the culture -- in the culture of medicine, in the culture of the country, and in the culture of African-Americans and their behavior," LaVeist tells WebMD. "It is much bigger than just health care alone.

“Health disparities track with disparities in education, in wealth, and in incarceration,” he says. “All these disparities track each other. It is not something those in the health industry alone can fix; it is a broader experience."

Ayanian says a lot could be learned from high-quality health plans that have eliminated racial disparity in health outcomes. But there's a problem here. Of the 151 plans studied, only a single plan had the same racial outcomes on more than one measure -- and that plan eliminated disparity on only two of the outcomes.

Other studies, Ayanian says, offer hints about how health plans can lessen disparities and improve outcomes for all patients.

"It is important for plans to have accurate and up-to-date information on whether patients are achieving good control; to provide reminders both to doctors and patients when they don't have good control,” Ayanian says. It is also important, he continues, to “potentially have nutritionists or health navigators work with patients to understand barriers to good control."

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By Daniel J. DeNoon, reviewed By Louise Chang, MD

SOURCES: Trivedi, A. The Journal of the American Medical Association, Oct. 25, 2006; vol 296: pp 1998-2004. John Ayanian, MD, associate professor of medicine and health care policy, Harvard Medical School, Boston. Thomas A. LaVeist, PhD, professor and director, Center for Health Disparities Solutions, Bloomberg School of Public Health, Johns Hopkins University, Baltimore.