Racial minorities and lower-income people typically fare far worse when it comes to health outcomes. And figuring out why has long been one of health care's black boxes. Forthcoming research may help shed light on what's driving those inequities -- and how the system can fix them.
What is needed? Better bedside manner, so patients actually trust their doctors. Communication that is easily understood by everyday people. And transparency about what medical care costs, plus a willingness to discuss how price points fit into consumers' health decisions.
Those ideas were highlighted in a white paper presented last week at a health communication conference sponsored by the Centers for Disease Control and Prevention. The findings, which will be published in full later this fall, are based on interviews with 100 health professionals and 65 "disadvantaged patients," along with a nationally representative survey of 4,000 consumers. The examination is part of a larger project funded by the Robert Wood Johnson Foundation, a health-focused nonprofit. It was conducted by the Altarum Institute, a research and consulting organization.
The paper suggests that "implicit bias" -- doctors and nurses subtly or subconsciously treating some patients differently than others -- or patients' perception of it could have consequences for people's health. Patients who felt that they had experienced bias based on factors like race, income or insurance were less likely to follow advice about medication, for instance, and ended up sicker in the long run.
"We for a long time have neglected the human element," said Chris Duke, director of Altarum's Center for Consumer Choice in Health Care, and the white paper's author. "The number one predictor of patient satisfaction is if your nurse listened to you. We neglect this at our great peril."
Duke stressed that the research isn't enough to draw conclusions about causality -- that feeling disrespected causes worse health. But the study builds on years of investigation that suggests implicit bias and how patients perceive it could contribute to differences in health outcomes.
Insurance status was the largest predictor of how patients viewed their doctor-patient interaction, Duke said. People on Medicaid, the state-federal health insurance program for low-income people, or who were uninsured, were more likely to perceive disrespect than those with private insurance or Medicare, which provides coverage for senior citizens and some disabled people. Income was the next predictor for how well people felt they were treated. After that came race.
Meanwhile, racial minorities and low-income people also were more likely to be sensitive to concerns about a doctor's bedside manner, and to seek out someone they thought would treat them well, Duke noted.
Often, these patients cue in on subtle behaviors, such as the doctor not making eye contact or not asking questions about their symptoms and health conditions, their lifestyle or their preferences on how to manage a disease. But that can be enough, Duke said, to keep people from seeking care, or following through on medical advice.
He recalled one interviewee: a lower-income black woman with high blood pressure. She said her physician never asked her meaningful questions about her health, instead just writing her a prescription. She was so dissatisfied she ignored the recommendation, meaning her condition only worsened.
"There's a huge need for provider training in communication and warmth, and the understanding that how you interact with your patients can have an implication ... on their health," he said.
That interaction could have major consequences for patients with chronic diseases, like diabetes or heart problems, noted Ben Handel, an assistant professor of economics at the University of California, Berkeley, who has researched health consumer decision-making. These patients need regular follow-up, but they are less likely to seek it out, because they aren't in significant pain. But if they don't get regular treatment, they could develop severe medical complications.
"If you feel like your doctor doesn't respect you, you're not going to go the doctor unless you have to -- and preventive care is something you don't get unless you have to," he said. "And that kind of stuff is in some ways the most important."
To address that, both Duke and Handel said it's worth examining how Medicaid pays doctors, so that they see more value in treating low-income patients. Currently, Medicaid reimburses physicians at a lower rate than do other insurance programs.
Encouraging more diversity in medical professions -- from a racial and a socioeconomic standpoint -- could also help, they said. That idea tracks with other suggestions researchers have made when brainstorming ways to tackle gaps in health care and to make the system more responsive to people who are typically overlooked.
"If you are a lower-income racial minority, and you walk into a hospital and none of the pictures of people look like you, and none of the staff looks like you, you may not feel welcome," Duke said. "People need to feel welcome for them to trust information, and trust guidance."
The paper also highlighted consumers' concerns about understanding their medical recommendations and how much their care costs. Expense in particular "is a big sticking point," Duke said, and it's something doctors have long been discouraged from discussing. But for patients, avoiding the subject means they're more likely to go without.
That's true across the board, but likely even more so for lower-income people, Handel said. "That's basic economic theory. If you're low-income and the marginal value of income is higher, you're going to be more price sensitive," he said.
The findings underscore a need for inclusivity, Duke said. "We heard many patients say, 'The system is for them and not for us,'" he said. "The fact that we have large disparities along the lines of income and race -- it shows there's a lot of ground to be covered."