Part III Audio Presentation

00:00 Speaker 1: Okay. I wanna go over to this side of the room. We’ll take two questions including one from the web and then back here.

00:05 Speaker 2: We have a question from a web listener, Nilka Ríos Burrows, who’s an epidemiologist with the Centers for Disease Control and Prevention. The question is, do you have any suggestions on how to improve data collection for surveillance among racial and ethnic minorities? National surveys are not useful due to small sample sizes of minority populations. Multiple local surveys to address all of the US minority populations would be too much of a daunting and expensive task for one agency to undertake, and some administrative data sets do not collect data on race or ethnicity.

00:40 David Williams: David Williams. The committee recommends the importance of the collection and monitoring of the appropriate racial and ethnic identifies, so we certainly can enhance our data systems by adding those elements, data elements, that would help us to monitor racial and ethnic status.

01:01 Speaker 4: And I would just add, there are a number of ways this can be accomplished. We’re sensitive to the shortcomings of surveys and the other methods that were mentioned, but as part of the registration process is the time when it is most directly addressed, so that it does not have to be a part of every patient encounter but rather can be linked back to a registration process.

01:26 S1: Okay. We’ll take another question over here.

01:28 Lucy Perez: Hi, Lucy Perez, President of the National Medical Association, and I must commend you as to the importance and for your courage, for presenting the truth about the disparities in healthcare, as it relates to communities of color. And I guess to Dr. Nelson, and this is a two-fold question. As a past president of the AMA, one of the things that you discussed was the fact that you were, or that there were, members of the committee that were surprised by the science. The National Medical Association since 1907, continuously our journal of the National Medical Association has reported on disparities in healthcare since 1907. And as Dr. Gary Dennis pointed out, we were very active to make sure that this report was in fact undertaken by the institute. Personally, how do you think we are going to get this information and get this information owned by other physicians about the issue of racism in medicine?

03:07 LP: And how are we going to turn things around given the fact that the increase in African-American physicians, which was the example that Dr. Williams utilized, over the last, what, 40 years has only increased in such a small amount? How are we going to get providers to make a significant change, given the disparities that have been illuminated by this report? That’s one. And two, you mentioned the importance of identifying or utilizing credentialing bodies. African-American in particular, representation on those bodies are small if in existence at all. What can be done from a policy level? And given the recommendations of this report, what oversight are you asking for from the federal government to assure, we’ve been talking about it for over a century and this report is just being released, what can we do to put some power behind your recommendations?

04:38 S1: Okay. Let’s see if Dr. Nelson and the others have an answer for you.

04:41 Speaker 6: Yeah. I indicated that some of us on the committee were surprised or shocked at the extent of the evidence. I would encourage you to download or order the complete report, it’s 500 pages. Part of that is a annotated bibliography of the evidence, the literature that we looked at, that runs 63 pages. We weren’t unaware of the extent of disparities, we were surprised at the breadth and depth of the evidence. And how to get the issue out? I think the important thing is, I think we are taking an important first step and we solicit the support of all of you, in terms of increasing the awareness of the report and its recommendations. One of our recommendations calls for adequate funding for the Office of Minority Affairs, and certainly that is an important step in terms of the government’s oversight of these issues.

05:42 S1: Okay, let’s go back over here.

05:44 Cee Cee Connelly: I’m Cee Cee Connelly from the Washington Post, two questions. The first is to go back to Maggie’s original question, you begin the executive summary saying that these disparities exist even among individuals with the same insurance and that this is not a study focused on access but people that have the access and are getting the care. I don’t quite follow then in other places where you are talking about socioeconomic factors and something going on within the health networks, I mean, could you give us a real world example? For instance, if Tony and I work at the same newspaper and have the same health insurance, what would happen that would potentially make his care less quality than mine? Can you give us a real world example of what you’re talking about here.

06:39 S1: Do you wanna take that?

06:39 Speaker 8: I think what we’re saying is we’re looking at people who are insured and insurance ranges, there’s a whole variety of types of insurance. In fact, some insurance plans, some insurers, some health employers should I say might contract with insurers who have limited choice in terms of providers, and that would be a very different experience for each patient.

07:01 CC: But that’s a different insurance. That speaks to the level of insurance that an individual has, not necessarily their race.

07:12 Dr. Lavisa-Morrey: Well I think that, this is Risa Lavisa-Morrey. One of the issues is that, if you look at minority populations, they’re disproportionately represented among insurance plans that may be more limited, and that is directly related to socio-economic status, the amount of income and so on. And I think that is the major point with regard to the type of insurance and the type of plan.

07:39 DW: David Williams. I wanna come back to your question because I’m glad you asked the question, because this is the take-home message that everyone has to be clear about. This report is not talking about access differences, it is not talking centrally about differences in insurance among racial and ethnic minority patients. The report is finding that even when you hold issues like insurance constant, and when you look at individuals getting into medical care, so your co-worker and you get into medical care, that if he’s a racial, ethnic minority person, his care is of lower quality. So, that is the problem. We are less clear on what all the factors are with definitive evidence, but the fact that these disparities exist, that are not accounted by access differences, is the important point, and your question highlights it.

08:24 CC: Well, it seems to me the two of you just gave very different responses. Dr. Lavisa-Morrey, you indicated that many minorities do not have the same level of insurance, which as an aside, sounds to me more of a poverty issue than a race issue. And yet, Dr. Williams, you seem to be saying, “No, when they’ve got the same exact insurance, the quality differs.” So, is it an insurance difference or is it not?

08:54 DW: I don’t think there’s conflict, David Williams speaking, if it’s both. These forces are multifactorial, they are complex, and both things are happening simultaneously. So, on average, racial and ethic minorities do not have as good insurance, but it’s also true that even when they do have as good insurance, the best evidence would suggest there are still differences in the care they receive.

09:16 S4: I think one of the best ways to look at this is to look at the studies that document this in the Medicare population. And must of the research has been done using that population. And the Medicare benefits are the same, so that we can isolate some of the factors by looking at different kinds of studies. But we had to really try to integrate a number of streams of evidence in order to make this recommendations.

09:45 CC: Well, but again, the Medicare example. As we all know, Medicare does not a prescription drug coverage. So again, many of the treatments, pharmaceutical treatments, that’s again, an economic or an insurance problem more than a race problem.

10:00 Speaker 10: Even when it’s the same, we see differences by race in prescribing for the same condition. Take coronary artery disease, we exactly the same occlusions and exactly the same arteries. When you control for the severity of illness, you still see differences. So, in the report, I’d like to call your attention to Figure One, which we really had some very interesting discussions, trying to do a graphic that shows, when you have the differences and then you control for the patient’s condition and the patient’s preferences, why we still see these differences. And the answer is, we don’t fully understand how to answer your question.

10:41 Speaker 11: In the committee, in seeking to understand how this could occur and the multiple complex factors that interplay, devoted attention to the historic antecedents, which is an important part of the report, and then a substantial part of the report is the environment in which these disparities that clearly exist are present. And it was part of understanding these multiple complex factors, only one of which is bias. The others play a role.

11:10 CC: Okay. Just a quick follow-up, and then I’ll stop badgering. This report was requested by Congress, and yet, in terms of recommendations to Congress, to policy-makers, it seems to me, with the exception of calling for more data collection and richer data collection, there are really no specifics. If I’m a member of Congress reading your report, for instance, you say that the Office of Minority Health should receive adequate funding. Why not say what that office needs in terms of funding and take a look at what its budget has been? Or, for instance, I was stunned to hear the figures on the number of minority doctors in America. If that’s such a big problem, why not suggest to Congress legislation that offers more financial incentives? Or, why not really give policy-makers something to work with?

12:09 Joseph Betancourt: I think part of our charge was to develop a set of recommendations that multiple policy-makers could use, and as such, this is Joseph Betancourt, as such, we try to identify key things. We already had a briefing yesterday on the Hill, both in the Senate and House side, where we helped expand on some of these. But let me give you a couple of examples of what we think they are very significant recommendations for policy-makers that are listed in our series of recommendations. We talk about patient protections, and the patient’s civil rights and applying those to publicly funded programs as well. We talk about increasing resources for the Office of Civil Rights to do monitoring of race, ethnicity and disparities. We talk about improving data collection and data collection systems, which is clearly a policy issue. We talk about supporting educational efforts and increasing diversity in healthcare workforce, and we hope to continue this discourse and help work with policy makers to help them operationalize some of these recommendations.

13:06 JB: Finally, something that is a hot policy issue right now is the clarification of Title Six and provisions for limited English proficient patients and interpretation services. This is something that’s a hot topic and we hope that the government, as a policy initiative can support interpreter services for patients as part of Title VI of the Civil Rights Act and explore how these could be funded effectively. There is no way that a physician can effectively communicate with the patient in the presence of a language barrier, or when there’s a family member or a child interpreting, there’s plenty of science to document that. And I think that that’s one very concrete recommendation that we have that could fall into place tomorrow.

13:50 S1: Okay, we’re running out of time, if we can get two questions over there quickly.

13:53 April Clark: Hi, my name is April Clark, and I’m from the Jacobs Institute of Women’s Health. Our organization with the Commonwealth Fund to help sponsor the report is holding a symposium in April on health disparities among women of color. And my question is, did you look at the literature and de-stratify by gender? And if not, why? Was that too daunting of a task or was there another reason?

14:17 Martha Hill: So this is Martha Hill, we know that these disparities also exist when you look at gender, age, and a variety of other factors. So within the studies, yes, there are studies, for example, where African American women or Native American men, you see differences compared to others of the same gender and or the same race. I think the differences are pervasive. It cuts across all conditions of health across the entire country. And we think it is a very, very serious moral issue that requires we all unify in paying attention and increasing our understanding and then moving to action, so.

14:55 S1: Okay. We’ll take two more questions very quickly. One here, one there.

14:58 Aranthan Steve Jones: Yes, greetings. My name is Aranthan Steve Jones. Good to see you again, Dr. Nelson, Joseph, etcetera. I’m working with Congressman Donna Christian-Christensen, chair of the Congressional Black Caucus. I’m a lead health LA and particularly on language issues as well as policy. First of all, I wanted to bring up the issue that we plan on using the IOM report. We thank you really for the great job that you’ve done, we plan on using the IOM report to actually be a framework for our hearing that we’re hosting April 12th. Looking at what HHS is doing on the issue of health disparities, particularly, and I think this kind of leads to my to the three quick questions I have.

15:35 S1: Three?

[laughter]

15:35 S1: One.

15:40 AJ: Yes, the first question number one is, the study speaks about issue of training, as well as the issue of trying to train more minority professional, health professionals, etcetera. Looking at HHS’ budget, particularly within HRSA there was a $14 million cut. Most of the programs that were cut actually were zeroing out of health professional training, particularly medical professionals, as well as health professionals. One question I wanted to know is how we actually gonna move on that issue, dealing with the current day-to-day thinking. The second thing is I wanted to know what role do you feel that the greater social comorbidities within our society play within the issue of Racing of Care, I mean, of care on the lines of race. And I think that that’s something to talk about. And then the last thing I wanted to know is, how much do you think that this issue as far as care and the treatment of care is the issue of the legacy of not being cared for, rather than the nuances of managed care penetration? So those are the three things I would like to ask.

16:36 MH: Martha Hill, I think any individual patient, an example, that was asked about the two individuals from The Washington Post with the same insurance, when you get to the individual patient, you do indeed have the legacy of that person’s previous experience in the context of their family and their culture. So all that does come right to the bedside or into the office. There’s no question that the greater social comorbidities are part of that, as is previous experience with the healthcare system, some of which may have been quite negative. So that is very much a part of what we are referring to. Finally, the training issue is extremely urgent and important and I would just point out partly for the [17:14] ____ stakeholder constituency group, we have a very severe shortage of nurses in this country, it is going to… There’s nothing showing right now that it’s turning around. A major question for the American public is, “Will there be a nurse to take care of me when I need one?” And this whole issue pertains not only to physicians, but it pertains to nurses and the increasing shortage of other allied health professionals and we need to pay attention to this.

17:35 S1: Okay, let’s get to our last question.

17:36 Chris Gibbons: Yeah, I just have two brief comments. One is just a point of clarification. And sorry, this is Chris Gibbons. Several people referred to one of your recommendations that increased funding for the Office of Minority Health. It’s actually increased funding for the Office of Civil Rights to enforce, just to point…

17:52 S2: Yeah, a misstatement.

17:53 CG: Yeah, right, just clarification there. Final thing is this question about with the same insurance status. I can say just from personal experience, I’m a minority physician trained in this country, that when I was in medical school, I was taught, and I wasn’t in medical school that long ago, that given the same clinical characteristics or whatever, if an African American patient… I was trained down south, just maybe that might make a difference, is that if an African American patient came to you, those patients in general are less likely to follow up with treatment, those patients are less likely to have strong support family networks, therefore those have clear implications for limb amputations or organ transplants. So that’s a, in my estimation, that’s a clear example of where insurance status has nothing to do with it. But just on race, you would make a differential recommendation to the follow up or for the treatment care plan of those patients based on what you were taught in medical school about the race and generalities of that population. Thank you.

18:52 JB: May I just respond to that. This is Joseph Betancourt. Speaking on the educational issue, I think there’s two areas where we need to expand on. Number one, we need to do a better job of teaching all healthcare providers, how we make decisions and what influences our decision making. I think that’s a critical piece. But second of all, I think we need to incorporate in our medical education tools and skills to be able to care for any patient who enters our door by paying respect and asking certain questions that would get out individual patient’s health beliefs, behaviors, practices, preferences, and that would allow us to do this effectively. Now, speaking to the funding issue. This aspect of cross-cultural education should not be marginalized. Speaks to the basic tenets of medical professionalism and to effective communication. Yes, HRSA and others have been cut in terms of funding and some of these funding for some of these programs have come through primary care training grants and otherwise. But I think it’s imperative that medical schools, that residency training programs really revisit the way our educational processes, and not look at this as an add-on or something that’s marginal, but really incorporate it because it is, in fact, good medicine.

20:05 S1: Okay, thank you. I’d like to thank you for attending, thank our panelists. I’d remind you that a recording of this briefing will remain on our website, as well as a link to the full text of the report at NationalAcademies.org.

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