Separate—Perhaps, Unequal? Physicians Treating Black and White Medicare Patients

New England Journal of Medicine Study: Physicians Who Care for Elderly Black Medicare Patients Report Greater Difficulty Getting Care for Their Patients

News Release
Aug. 4, 2004

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ASHINGTON, D.C.—To a large extent, different groups of physicians treat elderly black and white Medicare patients, providing new insights into possible explanations for the pervasive health disparities between blacks and whites, according to a study by researchers at Memorial Sloan-Kettering Cancer Center and the Center for Studying Health System Change (HSC) in the Aug. 5 New England Journal of Medicine.

Eighty percent of the primary care visits by elderly black Medicare patients were to 22 percent of physicians, and those physicians treating black patients were more likely to report difficulty getting hospital admissions, specialty referrals and other care for their patients, the study found.

Moreover, physicians treating black patients provided more charity care; derived a higher percentage of their practice revenue from Medicaid, the state-federal health care program for the poor; were less likely to be board certified in their primary specialty; and more often practiced in low-income neighborhoods than physicians treating white patients, the study found.

"The findings paint a picture of two health systems, where physicians treating black patients appear to have less access to important clinical resources and be less well trained clinically than physicians treating white patients," said Peter B. Bach, M.D., the study's lead author and a researcher in the Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering Cancer Center in New York City. Dr. Bach's earlier studies of racial disparity in cancer outcomes demonstrated that the poor quality health care received prior to a black patient's cancer diagnosis contributed, in part, to their lower rates of cancer survival.

The elimination of racial and ethnic disparities in health care is a goal of the federal government's Healthy People 2010 initiative, but the causes underlying these disparities have not been established. Minority patients and white patients to some extent reside in different locations and seek care in different settings, and the study found a geographic connection to physicians' likelihood to report greater obstacles to getting needed care for their patients

On average, a higher proportion of physicians practicing in communities where visits by white patients occurred reported they could access important health services for their patients than physicians who practice in communities where black patients receive care, the study found.

"It seems clear that if we are to eliminate racial and ethnic disparities in health care, we must examine the resources available to primary care physicians to coordinate patients' medical treatment," Bach said.

"The care of black and white patients rests to a large extent in the hands of different physicians, and health disparities may be driven by these two groups of physicians differing in their ability to provide high-quality care, because of community differences such as the availability of important health care services," said Hoangmai H. Pham, M.D., M.P.H., a coauthor and senior health researcher at HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation.

The study is based on information from HSC's nationally representative Community Tracking Study Physician Survey, which collects information from 12,000 practicing physicians, and Medicare claims information from a representative sample of 5 percent of Medicare beneficiaries. Data on physicians and patient visits were linked with the use of the physicians' unique provider identification number, and a total of 4,355 primary care physicians, 43,032 elderly Medicare patients and 150,391 patient visits were included in the study.

Key study findings include:

• Of all U.S. primary care physicians, 78 percent (68,311 physicians) accounted for 78 percent of visits by white patients but only 20 percent of all visits by black patients, according to the study. The remaining 22 percent of primary care physicians (19,492 physicians) accounted for 80 percent of all visits by black patients and 22 percent of visits by white patients.
• More than one in four visits (27.8%) by black patients took place with a physician who reported they could not consistently deliver high-quality care to all of their patients compared with less than one in five visits (19.43%) by white patients.
• Visits by black patients were more likely to occur with physicians who reported they could "not always" provide access for their patients to high-quality specialists (24% of visits by black patients vs. 17.9% for visits by white patients); high-quality diagnostic imaging (24.4% vs. 16.6%); and hospital admissions (48.5 % vs. 37%).
• Visits by white patients (86.1%) were more likely to occur with physicians who were board certified in their primary specialty area than visits by black patients (77.4%).

The study was coauthored by Deborah Schrag, M.D., M.P.H., and Ramsey C. Tate, B.S., Memorial Sloan-Kettering Cancer Center, and J. Lee Hargraves, Ph.D., Center for Studying Health System Change, and was supported by grants from the National Cancer Institute, The Robert Wood Johnson Foundation, the American Cancer Society, and the American Lung Association of New York City.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation's changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.