Minorities Less Likely to Receive Specialist Care

By Linda Carroll

July 21, 2021

(Reuters Health) - People of color are less likely than white patients to receive care from surgical specialists, medical specialists and pulmonary specialists, a new U.S. study suggests.

Analysis of nationally-representative data on more than 130,000 U.S. adults found that adjusted rate ratios (ARR) of visits to 29 different types of specialist were often lower among Black, Hispanic, Asian/Pacific and Native American patients compared to white individuals, according to the report published in JAMA Internal Medicine.

"If you take a step back, we already know that people of color in the U.S. have a lower life expectancy than white individuals," said the study's lead author, Dr. Christopher Cai, a resident physician at Brigham and Women's Hospital and the Harvard Medical School in Boston.

One factor may be that, despite a greater need among people of color in some areas for specialty care, doctors are granting more appointments to white individuals, Dr. Cai said. "The primary cause appears to be inequities in insurance," he added. "The bottom line is that we need to remove barriers to accessing health care."

One statistic that suggests disparities in health insurance may play a big role is the fact that one of the few areas in which people of color get similar access to specialists is nephrology.

"The unique thing about kidney disease," Dr. Cai said, "is that Medicare offers coverage for end-stage disease. An approach like Medicare for All would go a long way to reducing these disparities."

To take a closer look at the use of specialty services by race and ethnicity, the researchers turned to data from 2015 to 2018 Medical Expenditure Panel Survey (MEPS), which collects demographic (including self-reported race/ethnicity) and health care utilization data from a nationally representative sample of the noninstitutionalized, civilian U.S. population. Focusing on adults 18 years or older, Dr. Cai and his colleagues tabulated office and outpatient department visits to each physician specialty by each racial/ethnic minority group compared with the white population and adjusted for age.

The researchers included 132,423 individuals in their analysis. They found that Black individuals had low visit rates compared with white individuals to most specialties (23 of 29 versus 17 of 29 specialties). Among specialties with many visits, the Black versus white disparities were especially marked in dermatology (ARR 0.27), otolaryngology (ARR 0.38), plastic surgery (ARR 0.41), general surgery (ARR 0.55), orthopedics (ARR 0.59), urology (ARR 0.62), and pulmonology (ARR 0.63).

Black individuals had higher visit rates to nephrologists (ARR 2.78) and hematologists (ARR 1.65) and similar visit rates to internists, geriatricians, and oncologists.

The visit ratios for Hispanic and Asian/Pacific Islander individuals compared with white individuals were lower than 1.0 for 26 of 29 (89.7%) and 26 of 27 specialties (96.3%), respectively, and significantly lower for 20 of 29 (69.0%) and 21 of 27 specialties (74.1%). Similar patterns were seen for American Indian and Alaska Native individuals, although the 95% confidence intervals were wide.

The disparity among Hispanic versus white individuals was marked for dermatology (ARR 0.39), otolaryngology (ARR 0.47), and pulmonology (ARR 0.55). For Asian/Pacific Islander versus white individuals, ratios were markedly low for hematology (ARR 0.18), pulmonology (ARR 0.26), and otolaryngology (ARR 0.39).

"This study gives us a very detailed view into racial and ethnic disparities in the use of specialty care, which is an incredibly important metric of health care access given the rising proportion of U.S. adults with chronic conditions and multiple comorbidities," said Jamie Daw, an assistant professor of health policy and management at the Columbia University Mailman School of Public Health in New York City. "The findings are even more troubling given that people of color have higher rates of chronic conditions such as diabetes, stroke, and heart disease, which require specialist care. Yet, the authors find that communities of color are using these services less than white patients."

Daw believes the big problem is inequities in health care.

"The U.S. health insurance system is likely a significant driver of these disparities. A disproportionate share of people of color are enrolled in Medicaid or uninsured," Daw said in an email. "Because Medicaid pays lower prices than private insurance, fewer doctors take Medicaid patients, especially specialists. It would have been interesting for the authors to look at whether these disparities persisted within Medicaid or private insurance, or if the disparities were reduced after age 65, when Medicare eligibility begins," he noted.

"Health inequities in the U.S. are fundamentally driven by an unequal and unjust allocation of power and resources in the health care system and society at large," Daw said. "Addressing these disparities will require acknowledging that both interpersonal and structural racism drive differences like those found in this study, and developing policies that can fundamentally shift the distribution of resources and social attention to meet the needs of people of color."

"This important research shows that non-white individuals are less likely to see specialists, particularly ones who focus on procedures. Structural factors, including structural racism, may play a role in this disparity," said Dr. Carol Horowitz, a professor of population health and of medicine, and director of the Institute for Health Equity Research at the Icahn School of Medicine at Mount Sinai in New York City.

"I think it also points out limits of focusing on health care as sole driver of health disparities," Dr. Horowitz added. "For example, life expectancy is significantly greater in Asian populations in large part because of reduced deaths from heart disease and cancer. Yet, Asian populations were much less likely to see the oncology, cardiology, internal medicine and family doctors who primarily prevent and treat these diseases. Black populations who were just as likely to see these doctors have higher heart disease and cancer death rates. This means we must also look beyond differences in who sees doctors that do procedures, and focus on the non-health drivers of health disparities that stem from generations of structural racism, including poverty, lower quality education, pollution and stress."

SOURCE: https://bit.ly/2VOVMBS JAMA Internal Medicine, online July 19, 2021.