Inequity in health care delivery

[music]

0:00:04 Denise Brooks-Williams: The idea that racism has not been the underpinning to inequity is something that we have to reconcile, and that's a lot of dialogue, right? Going on, as we're having this conversation and thinking about disparities and inequities in 2020, we've had amplification of the idea that racism in our country really is a public health crisis. There is no one that should be sitting in the middle to be blamed, but everyone should be educated and compelled to do their part to make it better.

[music]

0:00:36 Narrator: Hello and welcome to Population Healthy, a podcast produced by the University of Michigan School of Public Health. In this season of Population Healthy, we'll examine health inequities through the lens of race in America by talking to public health researchers, experts, and others to learn more about what can be done to work toward health equity in our communities and across our country. This is Population Healthy Season 3: Race, Inequity, and Closing the Health Gap.

[music]

As we discussed in our last episode, race and health inequity are intertwined. And the social determinants of health, things like where you live, the air you breathe, the water you drink, and the food you can buy have a bigger impact on people's health than their individual choices. We also see this play out in the healthcare setting where people of color, not only face lower access to high-quality care, but also often face discrimination in the healthcare setting. The impacts of which can range from reluctance to seek care, to misdiagnoses, delayed treatment, and even death.

0:01:43 Susan Goold: So a disparity, which is really better termed an inequity is a difference in health or in healthcare that's not due to differences in biology or need. So for instance, someone with appendicitis who gets an ER visit and someone without appendicitis not getting ER visit, that's unequal treatment, but it's certainly not a disparity or an inequity because only the person with appendicitis really needs the ER visit. So people having heart attacks should all, if we want equity in healthcare, be offered similar services. Everybody having heart attacks should get the same or similar treatment and be offered similar services.

0:02:22 Narrator: Susan Goold is a Professor of Internal Medicine and Health Management and Policy at the University of Michigan. A physician herself, Goold teaches medical and public health students about ethical and legal issues in healthcare delivery. What exactly do healthcare professionals mean when they talk about disparities in healthcare delivery, and how can physicians learn to recognize and address inequities in treatment, practice, and resources for their patients?

0:02:49 Goold: In healthcare, we still have a very glaring issue having to do with health insurance. So if you don't have health insurance, you receive less care and you're less healthy than if you have it. There are still lots of people in the US without it. A second glaring issue really has less to do with healthcare, although it's related, and that is what people call the social determinants of health. So things like housing, water, having a job, racism, air quality, education, these have profound effects on health. And since they aren't the same for everybody, they create health inequities. They often also create healthcare inequities, because people without employer-based health insurance, for instance, will often have less access to care.

People who have experienced racism or housing insecurity, often have a more difficult time accessing healthcare and also doing what they need to do to take care of their health. It's certainly the case that we have documented inequities by race and ethnicity in the healthcare system. Women and minorities sometimes don't have their symptoms taken as seriously. Blacks and whites with similar pain complaints are treated differently. Blacks are less likely to get as much or any pain medication as whites. Those are all examples of healthcare delivery that differs by race, ethnicity, gender, age, appearance, etcetera. We know that they have worse health outcomes, and we also have documented, in many cases, that the care they receive is not as good or not as much.

0:04:30 Narrator: Many health inequities are rooted in economic factors, which themselves are rooted in a web of past policy decisions, discrimination, and myriad other factors. Goold's own research into the distribution of healthcare resources and funding has shown that decisions made by governments, policymakers, and hospital leaders can impact individual's healthcare access and quality of care.

0:04:53 Goold: This gets to the topic of what's called implicit bias. People are often perceived differently based on what might be completely irrelevant aspects of their appearance. People who are overweight are considered to be inactive, that's clearly not the case. People with darker skin may be considered to be more likely to be seeking drugs rather than having pain and needing drugs. I would say that doctors, nurses, people working in healthcare are just as vulnerable to those kinds of biases. I think we need to recognize and guard against that influencing diagnosis and treatment, obviously. And that's why I try to really bring it out in my teaching to say, "You know, are you thinking about this person in this way?"

The early clinical research that was done was done about heart disease, heart attacks, high blood pressure, etcetera, etcetera. Who was funding that research? The federal government. Who was running the federal government? White men with resources who at least perceive themselves as being at risk of heart attacks more than anything else. And some of you may know there's sort of a classic sign of someone clenching their fist over their chest, having chest pain. Those are typical symptoms of a heart attack, especially typical for a 70-kilogram white man. Those typical symptoms aren't so typical for some people. Women, diabetics... And there are a lot of racial and ethnic minorities with diabetes, more so than whites and the elderly, they don't have the typical symptoms. So in medical school, we were always taught symptoms or signs that you would see in this typical 70-kilogram man. They didn't say white man, but that's what it was. Those are some ways that medical treatment and diagnosis have provided advantages and disadvantages to different groups.

[music]

0:06:42 Goold: The medical profession has gradually, over time, begun to recognize that it's not just about learning anatomy and physiology and chemistry. You need to learn how to talk to people and how to listen to people if you wanna treat them well. We, physicians, need to first recognize disparities and inequities and our role in perpetuating them. That is so hard to do. Nobody wants to think that they treat people differently on the basis of skin color or gender. We all recognize that doing that consciously is wrong. We just need to remember that we are part of a culture that often or, at least sometimes, has these implicit biases, and we need to recognize and be on alert for those. Researchers have documented these inequities and disparities over and over and over again. And, again, turning to not just, "Oh, gee whiz, here's another disease where women or minorities do worse than men or whites." But, "How can we change that?" That's a much harder question to ask, but obviously a much more important one. Documenting disparities is one thing, but doing something about them, that's way more important. We need to listen to minorities to find out from them what is most important, how to allocate resources equitably and how to take care of them, how to take care of their health needs as individuals, but also as communities.

[music]

0:08:22 Narrator: For some people of color, there is a lack of trust in both doctors and the healthcare system. Denise Anthony is a Professor of Health Management and Policy at the University of Michigan School of Public Health and a Professor of Sociology. Anthony also serves as the Director of the Master’s in Health Informatics Program at the University of Michigan - a joint program offered by the School of Information and the School of Public Health. She studies the issue of trust between patients and doctors and its impact on care.

0:08:41 Denise Anthony: The relationship between race and ethnicity and trust in providers is a complex one. People have looked at the relationship between how patients trust their particular doctor and whether we see differences in trust by race and ethnicity. And some of that research has looked at whether the race and ethnicity of the doctor matches the race and ethnicity of the patient, and does that improve trust between doctors and patients? And there is some evidence that this concordance between providers can facilitate at least communication between doctor and patient, but it's not a guarantee that there will be higher levels of trust. What really does matter is the communication between the patient and the provider. So does the patient feel respected by their provider? Do they feel listened to? Do they feel like the doctor actually cares about and understands their health needs? When patients feel like that, they tend to have more trust. And unfortunately, what we often see in healthcare are experiences by racial and ethnic minorities, by African-American women, for example, in accessing OB-GYN care that they do not feel listened to by their provider, do not feel like the provider is taking their concerns as seriously. And so experiences like that for patients of color who feel like their doctors, their providers, are not responding or listening to them or respecting them, can lead to lower levels of trust.

0:10:27 Anthony: And that has consequences, we think, for sharing information with your provider, for following the advice and treatment prescribed by clinicians. Lower trust can even lead to avoiding healthcare in general because of experiences of discrimination or lack of respect in that doctor-patient relationship. Some of the research looks at the relationship of trust and healthcare, particularly by race and ethnicity, and that is sort of the trust in the healthcare system overall, what's sometimes called medical mistrust. Scholars have looked at how groups like racial and ethnic minorities like African-Americans in particular, experience inequality in healthcare, that leads to an overall mistrust of healthcare and how they might be treated, the kind of care they might get access to, whether they feel like they are getting access to all of the services that might be medically necessary for them. And so that's a little bit different, that's more like trust in the system overall. And we know when people doubt or have lower confidence or trust in institutions like healthcare, that's gonna be problematic for everyone because it might mean that they then use those institutions less or even avoid those institutions. And that can be problematic if we're talking about health and healthcare, not only for the individual, but for the public health.

0:12:04 Narrator: The Coronavirus pandemic has made the use of certain technologies like e-visits an essential part of receiving care for many. Anthony says that the implementation of new technologies can quickly expose the disparities within our healthcare system. And even before the pandemic, telehealth and other technologies brought to light important questions about equitable care.

0:12:25 Anthony: Telehealth is the use of electronic information and telecommunication technologies to support clinical healthcare or connections between patients and healthcare providers, and even among healthcare providers. The COVID-19 pandemic has rapidly changed the use of telehealth in the United States. Early on in the pandemic, many different health insurers, including Medicare and Medicaid and private insurers, made changes to coverage for telehealth services, essentially making them the same as an in-person visit. So that expanded the use of telehealth importantly because people couldn't go to the doctor for in-person visits, especially early in the pandemic, when that put people's health at risk.

Oftentimes, when new technologies are expanded and new innovations, those kinds of things are expanded with the hope that they will increase access to care and potentially decrease disparities that we know exist between various groups based on socioeconomic status, based on education, based on race and ethnicity and language, and even based on regional differences in access to healthcare. So by increasing access to telehealth, that could really expand access to health care for all groups. And yet, what we know from experience with new technologies in medical treatments, in new information technologies, when those are introduced into society, they often have the opposite effect in that they increase disparities across groups. Because it often is those with the most resources who can initially access and use those new technologies.

0:14:28 Anthony: With something like telehealth, we wanna make sure that everyone, all groups can access those technologies, particularly when, during the pandemic, that was one of the only ways to access your healthcare provider. So if there are disparities in access to those technologies, that's a real concern. Early evidence during the COVID pandemic showed some evidence of both increased disparities in a few particular places where they were looking at who was using telehealth. They found that there was lower use by racial and ethnic minority groups, by some older patients and by socioeconomic status, depending on the study. Whereas a few other studies were showing that because the expanded use of technology that could include telephone and online and video and texting, those things actually helped improve access for some of those groups. At this point, we're really trying to understand how the expansion of telehealth might impact groups because it has the potential to go either way. It has the potential to reduce disparities, but it can also exacerbate existing inequalities in health care.

0:15:53 Narrator: In her research, Anthony found that in some cases, beneficial health care technologies, like patient portals may not even be offered to individuals who would use them.

0:16:03 Anthony: When we think about access to telehealth and what's required, often your provider gives you information about the portal or the app in which you could do a telehealth visit, etcetera. I have done research and others have done research on looking at the characteristics of the patients in the US who are offered a patient portal from their provider. What we have seen in national data, as well as in some other studies that look at particular patient populations, there is some variation by race and ethnicity in which African-Americans and Asian-Americans are not offered access to an online patient portal at the same rate that white patients, for example, are offered a portal. So if you aren't even offered that access, then we shouldn't be surprised that we see some variation in which groups and patients are able to use those technologies. The fact that some groups are less likely to be offered those technologies is a real problem and a sign of some of the inequities in our healthcare system. Terrible situations, like the COVID-19 pandemic, reveal the extent of those inequalities in our healthcare system but also create some new opportunities, like the expansion of telehealth, which has been, prior to the pandemic, slowly increasing over time. With COVID, there's been a rapid expansion and there may be real benefits that can come from that expansion, but only if we take very seriously the inequities that exist in our healthcare system.

[music]

0:18:08 Narrator: Denise Brooks-Williams, a graduate of the University of Michigan School of Public Health, serves as a leader in one of the largest healthcare systems in the state of Michigan. Early in the pandemic, she was appointed to Michigan Governor Gretchen Whitmer's Coronavirus Task Force on Racial Disparities. The task force is charged with investigating and making recommendations to address racial disparities in healthcare in the wake of COVID-19.

0:18:31 Brooks-Williams: While COVID is a health concern, it certainly impacted the community incredibly broadly. Our schools had to close abruptly, lots of focus on essential workers in all the industries that they existed, and it magnified the gaps that exist from an equity perspective in the community. The wonderful thing about the task force, is as it was convened, the mission was to act. So the actions initially were very, very focused on what had been immediately seen as equity issues with COVID itself. So an accelerated path towards testing and ensuring that there was access for individuals that may not have had natural relationships with physicians, which early on was a barrier to testing itself, but then quickly expanded into work around, how will we have a healthier community in Michigan? And that healthier community being one that would be equitable in the delivery of care? Policy was put in place, there was strong encouragement that physicians would be activated and treating all equal in terms of getting them in and having the resources and support needed.

In addition to that, there's work that's going on around telehealth and making sure that if ever we go back to a restricted delivery studying, that we have the right infrastructure in place so that all groups will have access to care. There's also work going on around provider connections and making sure that, in particular, from Medicaid recipients that they have an adequate supply of physicians to care for them, and that those same physicians have the resources that they're going to need to treat them. Just incredibly powerful, I think, to have from a governmental level the partnership, leadership and direction that says we're seeing in our state this huge gap in outcomes and we wanna do something about it. And that's really been the spirit of the group.

0:20:23 Narrator: One of the key recommendations to come from the task force is training to help mitigate inequities in health care delivery during the pandemic and beyond.

0:20:31 Brooks-Wiliams: So we have policy that has come into play, which now requires that all licensed professionals in Michigan will have implicit bias training. And while the training itself is not mandated, the requirement that it be done is. And so that created a lot of dialogue, and many of our health systems were on that journey, but this would just magnify and make sure that it happens.

[music]

0:20:57 Brooks-Williams: Some of the contributors to health care inequities in healthcare today, definitely from a delivery perspective, revolve sometimes around provider education and really having a foundation and an understanding of the differences that might exist that people are unaware of. It's a huge influencer in our current society around how people experience care and do they get relief from the things that they're dealing with. Currently, healthcare professionals fortunately are receiving training. That really does help to give them greater awareness of bias in healthcare equity issues, and I think that I'm seeing that be magnified in a way that's much greater than it ever has been. Some of that I know is a direct result of the experience that a lot of states had with COVID-19 and its adverse impact on communities of color, in particular. A lot of times what organizations or communities are focused on is facilitated sessions and really giving a lens to what it means to have the inequities and disparities that exist in care and how the providers can have an impact in improving that.

Over my career, the focus on inequities in healthcare has definitely evolved. I would say, honestly, I have seen periods of ebb and flow at the beginning of my career, which would be the early 90s. I feel there was a very heightened focus and it was really more around diversity and leadership and governance. I've seen that expand, fortunately, to include more delivery and care and provider education, as well as the awareness of social determinants and how they play into what happens for people who experience the healthcare system.

[music]

0:22:49 Brooks-Williams: Often, I see opportunities to be engaged in awareness. It may be redirecting behavior or activity, and I don't say that coming from a perspective of being a person of color. I'd like to think it's just being a practitioner in the space and being hyper-sensitive to the things that we can say or do, or the policies that we can seek to put in place that may not give everyone that fear opportunity to have the best outcome. Physicians do, I believe, come to healthcare to help people. And I don't think immediately when you say to them that there is a difference in outcome that they think it's because of something that they've done. Data is very powerful in this space.

So with electronic health records, we can have much better capture of data. And then if we can take that and marry it to outcomes, the data for many physicians is indisputable. And so I think it's never a scenario of making an accusation or suggesting that someone is doing something from a place of wanting to create harm, but it's showing data and saying, "Why is it, if everything is being done the same for women in childbirth, do we have this disparity outcome for Black moms?" When you put that in front of any physician colleagues that I've had, they listen and they typically want to know what it is that can be done better and different to not get that outcome.

[music]

0:24:10 Brooks-Williams: From a profound perspective, I think our society does not enjoy its richness of all citizens because we are still working through how do we eliminate any inequities in care that exist. And that's been a long journey, and I think it's one hopefully that's having higher magnification today.

[music]

0:24:37 Narrator: On the next edition of Population Healthy...

0:24:39 Speaker: Generally speaking, when we hold things in, we think that we're helping ourselves because talking about it is really scary. If you think about a can of pop and it's consistently being shaken, stirred, rolled around, dropped and not opened up, then you know what's next, right? You know that that can can either explode or when you do decide to open it up, it's gonna have some really forceful effects coming out.

[music]

0:25:09 Narrator: Thanks for listening to this episode of Population Healthy: Race, Inequity and Closing the Health Gap from the University of Michigan School of Public Health. We hope you learnt something that will help you make the world a healthier place. Please subscribe or follow our podcast on Apple Podcast, Google Play, Stitcher or Spotify, or wherever you listen to podcasts. Interested in studying public health with us, join our interest list by going to our homepage publichealth.umich.edu and check out our programs and degrees and other helpful resources across our website. Be sure to follow us at @umichsph on Twitter, Instagram and Facebook to join the conversation, learn more from Michigan Public Health experts and share episodes of the podcast with your friends and followers. You can also check out the show notes on our website, publichealth.umich.edu/podcast for more resources about the topics discussed in this episode. If you wanna stay up to date with the latest research and expertise from Michigan Public Health, subscribe to our weekly newsletter, Population Healthy. Head to publichealth.umich.edu/news/newsletter to sign up and be sure to join us next time. Thanks for listening and doing your part to make the world a healthier place for all.