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MODEST AND UNEVEN: While nearly half of U. S. physicians identify language or cultural communication
PHYSICIAN EFFORTS TO barriers as obstacles to providing high-quality care, physician adoption of practices
to overcome such barriers is modest and uneven, according to a new national study
REDUCE RACIAL AND
by the Center for Studying Health System Change (HSC). Despite broad consen-
ETHNIC DISPARITIES
sus among the medical community about how physicians can help to address and,
By James D. Reschovsky and Ellyn R. Boukus ultimately, reduce racial and ethnic disparities, physician adoption of several recom-
mended practices to improve care for minority patients ranges from 7 percent report-
ing they have the capability to track patients’ preferred language to 40 percent report-
ing they have received training in minority health issues to slightly more than half
reporting their practices provide some interpreter services. The challenges physicians
face in providing quality health care to all of their patients will keep mounting as the
U.S. population continues to diversify and the minority population increases.
2
Center for Studying Health System Change Issue Brief No. 130 • February 2010
Table 2
Patient Communication Difficulties among U.S. Physicians, by Level of Interpreter Support, 2008
Technology and the Centers for Medicare Addressing Disparities Varies by Apart from the minority composition
and Medicaid Services that include these Practice Characteristics of physicians’ patient panels, practice type
capabilities in definitions of “meaning- also demonstrates a strong association with
Adoption rates vary not only across the dif- efforts to address disparities.12 Physicians
ful use” of EMRs qualifying for subsi-
ferent tools, but also according to practice in solo and group practices were less likely
dies.
characteristics (see Table 3).11 Physicians to adopt measures to address disparities
Reporting of patient demographic
in practices with a greater share of minor- than those in institutional practices, such as
information and access to patient-pre-
ity patients were more likely to adopt each hospitals, health maintenance organizations
ferred language. Less than one in four
of the measures to address disparities. For (HMOs) and medical schools. For example,
physicians (23%) indicated they receive
example, almost twice as many physicians nearly 90 percent of physicians in group-
reports on patient demographics. Among
reported providing interpreter services or staff-model HMOs reported providing
physicians in high-minority practices, only
in practices with a majority of minority interpreter services, compared with 34 per-
a slightly higher percentage (29%) received
patients, relative to those in low-minority cent of physicians in solo or two-physician
demographic reports.
practices—less than 10 percent minor- practices. Physicians in HMOs also were
Knowing what language a patient ity patients (72.3% vs. 39.2%). Similarly,
prefers is important for arranging and more than 10 times as likely as those in
there were large differences in provision of solo or two-physician practices to routinely
coordinating interpreter services for patient-education materials in foreign lan-
patients with limited-English proficiency use IT to access information on patients’
guages (60% vs. 24%), routine use of IT to preferred language.
or matching appropriate physicians to access patients’ preferred languages (10.5%
patients. Twenty-two percent of physicians vs. 4.3%) and quality reporting by racial or
indicated their practice has IT capable Policy Implications
ethnic group (16.8% vs. 8.2%).
of reporting patients’ preferred language Weighting physicians by the propor- Despite broad consensus among the medi-
(findings not shown), but only a third of tion of minority patients they treat allows cal community about how physicians can
these physicians (7%) routinely used this a rough estimate of the distribution of help to address and, ultimately, reduce
capability. minority patients treated by physicians disparities, physician adoption of several
Reporting of quality of care delivered using various tools to reduce disparities. recommended practices to improve care
to minority patients. Nearly nine out of 10 For example, while 56 percent of physicians for minority patients remains low. Cost and
physicians lacked a formal means to assess provided interpreter services, 64 percent lack of reimbursement for these activities
the quality of care provided to patients of minority patients were treated by physi- are likely among the largest obstacles to
across racial and ethnic groups. Only 11.8 cians in practices with interpreter services. implementation in physician practices.
percent of physicians reported access to And, 14 percent of minority patients were The tools most commonly adopted tend
reports on the quality of care they provide treated by physicians who received reports to be the least expensive to implement:
stratified by patient race or ethnicity. on the quality of care for minority patients provision of patient-education materials
(findings not shown). in foreign languages, which can often be
3
Center for Studying Health System Change Issue Brief No. 130 • February 2010
Table 3
U.S. Physicians and Disparity Reduction Efforts, by Minority Patient Composition and Practice Type, 2008
Disparity Reductiton Tools
All Average Providing Providing Trained in Receiving Routinely Receiving
Physicians Minority Interpreters2 Any Minority Patient Use IT to Quality
Patients1 Patient- Health Demographic Access Reports4
Education Issues4 Reports4 Patients'
Materials Preferred
in Non- Language2
English
Language3
All Physicians 100% 32.7% 55.8% 40.1% 40.3% 23.2% 7.3% 11.8%
Percent Minority Patients
Low (<10%) (R) 17.8 3.2 39.2 24.1 35.7 17.9 4.3 8.2
Medium (10-50%) 61.4 27.3 54.5** 37.3** 37.3 22.3* 7.0** 10.8
High (>50%) 20.8 73.8 72.3** 59.9** 51.5** 28.8** 10.5** 16.8
Type of Practice
Solo/2
31.2 30.9 34.4 29.8 36.1 19.7 3.1 13.9
Physicians (R)
Group (3-5
15.4 28.1 42.4** 32.5 31.7 18.4 4.2 9.2
Physicians)
Group (6-50
19.2 29.5 51.5** 33.3 32.5 21.0 5.0* 9.3
Physicians)
Group (51+
6.1 25.9 72.7** 46.9** 38.4 25.5 10.4** 8.8
Physicians)
Group/Staff
3.5 35.7 90.6** 75.1** 71.3** 48.7** 33.2** 23.4
HMO
Institutional
23.6 41.6 85.7** 53.0** 52.5** 28.2** 11.9** 12.2
Practice5
* Difference from reference group, as indicated by (R), is statistically significant at p<.05. ** at p<.01.
1
This is the percent of patients treated who are black or Hispanic, as reported by physicians.
2
Excludes physicians who report having no non-English speaking patients.
3
Population consists of physicians whose practices treat at least one of the following chronic conditions: diabetes, asthma, depression, congestive heart failure.. Population excludes physicians who report
having no non-English speaking patients.
4
Excludes physicians who report having no minority patients.
5
Institutional practice includes community health centers, hospitals, and medical school/university.
Source: HSC 2008 Health Tracking Physician Survey
downloaded from the Internet for free, and vices. This may help to explain their higher affected and the financial burdens imposed
training in minority health. On the other adoption rates relative to solo and small- on providers. Low payment rates, especially
hand, IT systems that can support report- group practices. in Medicaid and SCHIP, mean that aggres-
ing on patient care by race, ethnicity or Competent interpreter services are a key sive enforcement could hinder physicians’
language, as well as interpreter services, are step in improving physician-patient com- willingness to treat these patients.
expensive and less common. For instance, an munication when language barriers are a Therefore, it is not surprising that physi-
encounter with an interpreter involves the problem. Under federal law—Title VI of cians working in hospital and other insti-
cost of paying the interpreter and requires the Civil Rights Act—health care providers tutional settings were more likely to have
the physician to spend more time with the who treat patients with public insurance— interpreter services available than physicians
patient—time that could have been devoted Medicare, Medicaid and the State Children’s in solo or group practices. As of 2008, all 50
to seeing more patients. Larger physician Health Insurance Program (SCHIP)—have states had laws governing language services
organizations and those with higher concen- an obligation to provide interpreter services in health care settings.13 However, these
trations of patients needing interpretation to those patients. However, enforcement is laws vary by state, languages and/or condi-
services can take advantage of scale econo- subject to judgments about the number of tions covered, provider setting, and level of
mies to more efficiently provide these ser- patients with limited-English proficiency enforcement. Moreover, only some states
4
Center for Studying Health System Change Issue Brief No. 130 • February 2010
5
Center for Studying Health System Change Issue Brief No. 130 • February 2010
Data Source Human Services, Healthy People 2010: ity health training, have IT available to
Understanding and Improving Health obtain patients’ preferred languages, and
This Issue Brief presents findings from (November 2000). receive quality reports according to race
the HSC 2008 Health Tracking Physician or ethnicity, while surgeons were more
7. Baker, David W., et al., “Health Literacy
Survey, a nationally representative mail likely to provide interpreters.
and Mortality Among Elderly Persons,”
survey of U.S. physicians. The sample of Archives of Internal Medicine, Vol. 167, 13. Au, Melanie, Erin Fries Taylor and
physicians was drawn from the American No. 14 (July 2007). Marsha Gold, Improving Access to
Medical Association master file and Language Services in Health Care: A
8. Roter, Debra L., et al., “Effectiveness
included active, nonfederal, office- and Look at National and State Efforts, Policy
of Interventions to Improve Patient
hospital-based physicians providing at Brief, Mathematica Policy Research,
Compliance: A Meta-Analysis,” Medical
Washington, D.C. (April 2009).
least 20 hours per week of direct patient Care, Vol. 36, No. 8 (August 1998).
care. Residents and fellows were excluded. 9. Roughly three-quarters of physicians are
The survey includes responses from more in practices that treat patients with at
than 4,700 physicians and had a 62 per- least one of the four focal chronic condi-
cent response rate. Estimates from this tions. Ninety percent of primary care
survey should not be compared to esti- physicians are in practices that treat all
of the four conditions.
mates from HSC’s previous Community
Tracking Study Physician Surveys because 10. Betancourt, Joseph R., et al., “Defining
of changes in survey administration mode Cultural Competence: A Practical
Framework for Addressing Racial/Ethnic
from telephone to mail, question wording,
Disparities in Health and Health Care,”
skip patterns, sample structure and popu- Public Health Reports, Vol. 118 (July/
lation represented. More detailed infor- August 2003).
mation on survey content and methodol-
11. All six measures are not relevant to all
ogy can be found at www.hschange.org. physicians. For example, interpreter
services are not relevant to the 3.5 per-
cent of physicians with no non-English
speaking patients. Moreover, we are not
able to assess whether the quarter of
physicians in practices that do not treat
any of the four major chronic conditions
provide patient information materials in
languages other than English for condi-
Funding Acknowledgement tions they do treat. See Table 2 notes for
This research was supported by the more information.
Robert Wood Johnson Foundation. 12. In addition to practice type and percent-
age of minority patients, other physi-
cian and practice characteristics are
ISSUE BRIEFS are published by the
associated with adoption of practices
Center for Studying Health System Change. to reduce racial and ethnic disparities.
Minority—black and Hispanic—physi-
600 Maryland Avenue, SW, Suite 550
Washington, DC 20024-2512
cians are more likely to implement each
Tel: (202) 484-5261 of the tools than white, non-Hispanic
Fax: (202) 484-9258 physicians. With the exception of receiv-
www.hschange.org
ing patient demographic reports, the
President: Paul B. Ginsburg same is true for physicians practicing
in large urban areas relative to rural
areas. Across specialties, primary care
physicians and medical specialists were
more likely than surgeons to provide
patient-education materials in languages
other than English, have received minor-
HSC, funded in part by the Robert Wood Johnson Foundation, is affiliated with Mathematica Policy Research