Modest and Uneven: Physician Efforts to Reduce Racial and Ethnic Disparities

Modest and Uneven: Physician Efforts to Reduce Racial and Ethnic Disparities

Issue Brief No. 130
February 2010
James D. Reschovsky, Ellyn R. Boukus

Although close to half of all U.S. physicians recognize language or cultural communication obstacles as challenges to delivering high-quality care, their adoption of strategies to overcome these barriers remains limited and inconsistent, according to a new national study conducted by the Center for Studying Health System Change (HSC). Despite widespread agreement within the medical profession about how physicians can contribute to addressing and ultimately narrowing racial and ethnic disparities, the uptake of recommended practices for improving care for minority patients varies considerably -- from just 7 percent of physicians reporting the ability to track patients' preferred language, to 40 percent indicating they have undergone training in minority health topics, to slightly over half reporting that their practices offer some form of interpreter services. The difficulties physicians encounter in delivering quality health care to all patients are set to intensify as the U.S. population grows increasingly diverse and the minority population expands.

Physicians' Role in Addressing Racial and Ethnic Disparities

Starting in 2003, the federal government has used the National Healthcare Disparities Report to document substantial differences in health care quality experienced by various racial and ethnic groups across the United States on an annual basis. According to the most recent report released in May 2009, minimal progress has been achieved in narrowing these quality gaps.

While variations in insurance coverage and other patient, community, and health system factors play a role in disparities, research shows that disparities can also emerge during interactions between patients and physicians. [1] Both the Institute of Medicine and the National Quality Forum, along with other organizations, have outlined actions that physicians and their practices can pursue: 1) reducing language and cultural barriers that impede communication between certain minority patients and their doctors; and 2) building practice-level information systems to help eliminate language and cultural obstacles and deliver feedback on care quality across racial and ethnic populations. [2]

Building on these recommendations, the nationally representative 2008 HSC Health Tracking Physician Survey queried physicians about the steps they and their practices have taken to lower language and cultural barriers and produce practice-level information aimed at enhancing care for minority patients (see Data Source). Specifically, the survey asked physicians the following:

- Whether their practice offers interpreter services;
- Whether their practice makes patient-education materials available in languages besides English;
- Whether they have undergone training in minority health topics;
- Whether they receive reports that include patient demographic data, such as race or ethnicity;
- Whether their practice has information technology (IT) capable of identifying patients' preferred language; and
- Whether they receive reports on the quality of care delivered to minority patients.

Reducing Language and Cultural Barriers

Effective communication between patients and caregivers is a fundamental requirement for quality medical care. In 2008, nearly half (48.6%) of all U.S. physicians indicated that difficulty communicating with patients due to language or cultural barriers posed at least a minor challenge to their ability to deliver quality care, although fewer than 5 percent considered it a major problem. When physicians fail to address communication barriers -- or when the measures they take prove ineffective -- the result may be widening disparities in care quality across racial and ethnic groups.

Interpreter services. A growing number of people in the United States speak a language other than English at home (56 million people aged 5 and older in 2008, with 44% of them reporting they speak English less than "very well"). [3] These figures underscore the critical need for interpreter services to enhance care quality for patients who have limited English proficiency. [4]

Furthermore, providers are legally required to furnish necessary interpreter services, at least for publicly insured patients. While nearly 97 percent of physicians treat at least some patients who do not speak English, only slightly more than half of all physicians (56%) were affiliated with practices that offered interpreter services in 2008 (see Table 1). Among physicians whose practices did offer interpreter services, 44 percent were in practices that provided interpretation in just one language, 16 percent were in practices covering two languages, and the remainder were in practices offering interpretation in three or more languages, including telephonic translation services.

Notably, among physicians whose patients speak different languages, those practicing in settings with interpreter services were actually more likely to report communication challenges than those without access to such services, even after controlling for the share of minority patients in their panels (see Table 2). While this finding may reflect heightened demand for interpreter services in practices already struggling with language barriers, it could also suggest that available interpreter services are not always accessible when needed or are insufficient in quality. [5] Nearly one in five physicians (18.8%) reported being unable to obtain interpreter services in the preceding 12 months that they considered medically necessary. Additionally, among physicians whose practices provided interpreter services, it remains unclear how many offer professional interpretation rather than relying on staff members who may lack full fluency in the language, familiarity with medical terminology, or awareness of cultural nuances.

Non-English, written patient-education materials. Low health literacy -- defined as a limited ability to obtain, process, and understand the health information and services necessary for making informed decisions [6] -- is linked to less frequent use of preventive services, higher rates of hospital and emergency department visits, and worse health outcomes. [7] Minorities, particularly those who are not proficient in English, are disproportionately represented among people with low health literacy.

While other care management approaches have been shown to be more effective than written materials for educating and engaging patients in self-care, physicians can support health literacy by offering patients written information about their conditions and instructions for self-management. [8] Making patient-education materials available in appropriate languages for patients with limited English proficiency further promotes health literacy. Among physicians in practices that treat patients with any of four common chronic conditions -- asthma, diabetes, congestive heart failure, and depression -- 72 percent in 2008 reported that their practice provides patient-education materials for at least one of these conditions. [9] However, only 40 percent of physicians in these practices indicated they offer patient-education materials in languages other than English for at least one of the conditions.

Physician training in minority health. Culturally competent care focuses on understanding cultural differences and how they intersect with individuals' health expectations and behaviors, disease incidence and prevalence, and treatment outcomes. The objective of minority health education is to build practitioner skills for tailoring care to meet patients' culturally specific needs. [10] Approximately four in 10 physicians in 2008 reported having received some form of minority health training, such as cultural competency education, through professional meetings, workshops, or continuing medical education courses. However, the survey question did not evaluate the nature of the training, how comprehensive it was, or how recently it occurred. Although physicians in high-minority practices (defined as those with 50% or more minority patients) were more likely than others to have received minority health training, only half had actually done so.

Information Feedback to Physicians

Additional prerequisites for improving care for minority patients include the ability to identify these patients, know what language they prefer, and monitor the quality of care they receive. Although such information could theoretically be maintained in purely paper-based recordkeeping systems, recent national initiatives have concentrated on electronic medical records (EMRs). Progress in this direction is expected to accelerate in the near term due to incentives established by the American Recovery and Reinvestment Act of 2009 and emerging guidelines from the Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services, which incorporate these capabilities into definitions of "meaningful use" of EMRs that qualify for federal subsidies.

Reporting of patient demographic information and access to patient-preferred language. Fewer than one in four physicians (23%) indicated they receive reports on patient demographics. Even among physicians in high-minority practices, only a marginally higher share (29%) received such demographic reports.

Understanding a patient's preferred language is essential for arranging and coordinating interpreter services for those with limited English proficiency or for matching patients with appropriate physicians. Twenty-two percent of physicians reported that their practice has IT capable of identifying patients' preferred language (findings not shown), but only a third of these physicians (7%) made routine use of this capability.

Reporting of quality of care delivered to minority patients. Close to nine out of 10 physicians had no formal mechanism for evaluating the quality of care delivered to patients across different racial and ethnic groups. Just 11.8 percent of physicians reported having access to reports on care quality stratified by patient race or ethnicity.

Addressing Disparities Varies by Practice Characteristics

Adoption rates differ not only across the various tools but also based on practice characteristics (see Table 3). [11] Physicians in practices serving a larger proportion of minority patients were more likely to implement each of the measures aimed at addressing disparities. For instance, nearly twice as many physicians reported offering interpreter services in practices where minority patients constituted a majority, compared with those in low-minority practices -- defined as having less than 10 percent minority patients (72.3% vs. 39.2%). Similarly, substantial differences were observed in the provision of patient-education materials in foreign languages (60% vs. 24%), routine use of IT to access patients' preferred languages (10.5% vs. 4.3%), and quality reporting by racial or ethnic group (16.8% vs. 8.2%).

Weighting physicians by the proportion of minority patients they treat provides an approximate estimate of how minority patients are distributed among physicians utilizing various disparity-reduction tools. For example, while 56 percent of physicians offered interpreter services, 64 percent of minority patients were treated by physicians in practices with such services available. Similarly, 14 percent of minority patients were seen by physicians who received reports on the quality of care for minority patients (findings not shown).

Beyond the minority composition of physicians' patient panels, practice type also shows a strong correlation with efforts to reduce disparities. [12] Physicians in solo and group practices were less likely to adopt disparity-reduction measures than those in institutional settings, such as hospitals, health maintenance organizations (HMOs), and medical schools. For example, nearly 90 percent of physicians in group- or staff-model HMOs reported offering interpreter services, compared with just 34 percent of physicians in solo or two-physician practices. Physicians in HMOs were also more than 10 times as likely as those in solo or two-physician practices to routinely use IT to access information about patients' preferred language.

Policy Implications

Notwithstanding broad consensus within the medical community regarding how physicians can help to address and ultimately narrow disparities, the adoption of recommended practices for improving care for minority patients remains low. Cost considerations and the absence of reimbursement for these activities are likely among the most significant barriers to implementation in physician practices.

The tools most frequently adopted tend to be those that are least costly to implement: offering patient-education materials in foreign languages, which can often be downloaded from the Internet at no cost, and minority health training. By contrast, IT systems capable of supporting reporting on patient care by race, ethnicity, or language, as well as interpreter services, are expensive and less widely adopted. For example, an encounter involving an interpreter entails the cost of paying the interpreter and requires the physician to spend additional time with the patient -- time that could otherwise be used to see more patients. Larger physician organizations and those with higher concentrations of patients needing interpretation services can leverage economies of scale to deliver these services more efficiently. This may partly explain why their adoption rates exceed those of solo and small-group practices.

Competent interpreter services represent a critical step in strengthening physician-patient communication when language barriers exist. Under federal law -- Title VI of the Civil Rights Act -- health care providers who treat publicly insured patients through Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP) are obligated to provide interpreter services to those patients. However, enforcement depends on assessments of how many patients with limited English proficiency are affected and the financial burden placed on providers. Low reimbursement rates, particularly in Medicaid and SCHIP, mean that vigorous enforcement could actually discourage physicians from treating these patient populations.

It is therefore unsurprising that physicians practicing in hospital and other institutional environments were more likely to have interpreter services at their disposal than those in solo or group practice settings. As of 2008, all 50 states had enacted laws governing language services in health care settings. [13] Nevertheless, these laws differ by state, languages and/or conditions covered, provider setting, and level of enforcement. Moreover, only some states offer reimbursement for interpreters through Medicaid and SCHIP, and frequently these states rank among those with the smallest populations of residents with limited English proficiency.

Even when interpreters are available, the benefit to patients can be uncertain. Providers frequently rely on patients' family members, untrained bilingual staff, or other ad-hoc interpreters. The fact that the availability of interpretation services bears little relationship to physicians' reports of difficulties with language and cultural barriers raises concerns about effectiveness. Relatively little policy attention has been directed toward clarifying the legal framework surrounding interpreter services and establishing uniform standards. However, in September 2009, a new organization -- the Certification Commission for Healthcare Interpreters -- was created to develop national certification for health care interpreters, and the National Council on Interpreting in Health Care is working on national training standards for interpreters.

Many private insurers' physician directories include information about languages spoken by participating physicians, and the public sector could consider taking similar steps to help direct patients to physicians who speak their language or provide suitable interpreter services. Additionally, policy makers will likely need to consider further subsidies to support interpretation services.

The challenges physicians face in delivering quality health care to all their patients will continue to grow as the U.S. population becomes more diverse and the minority population increases. Although disparities can originate from factors beyond the physician-patient encounter, physicians' ability to communicate effectively with patients and understand their cultural and social context remains essential for caring for a diverse patient population.

Notes

1. Smedley, Brian D., Adrienne Y. Stith and Alan R. Nelson (eds.) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine (2003).

2. These measures were included in the 2003 Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which identified physician bias, stereotyping and uncertainty on the part of providers as factors influencing disparities. Similar recommendations are contained in National Quality Forum guidelines.

3. These estimates come from the 2008 American Community Survey 1-Year Estimates published by the U.S. Census Bureau. The full table can be found on the Census Bureau Web site at Table S1601, Language Spoken at Home.

4. Use of interpreters in clinical encounters, especially those who are professionally trained, has been associated with higher provider and patient satisfaction (Carrasquillo, Olveen, et al., "Impact of Language Barriers on Patient Satisfaction in an Emergency Department," Journal of Internal Medicine, Vol. 14, No. 2 (February 1999)) and improved health outcomes via reductions in errors and enhanced patient comprehension and utilization (Jacobs, Elizabeth A., et al., "Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services," American Journal of Public Health, Vol. 95, No. 5 (May 2004)). Conversely, language barriers are commonly associated with lack of a usual source of care, lower health service utilization, poor adherence to and misunderstanding of treatment and follow-up regimens, lower satisfaction, and higher incidence of medical complications (Karliner, Leah S., et al., "Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency? A Systematic Review of the Literature," Health Services Research, Vol. 42, No. 2 (April 2007)).

5. The relationship between the percentage of patients with whom physicians have difficulty communicating and the number of languages for which their main practice provides translation services is only slightly attenuated after adjusting for the percentage of Latinos, Asians and Native Americans who are treated.

6. U.S. Department of Health and Human Services, Healthy People 2010: Understanding and Improving Health (November 2000).

7. Baker, David W., et al., "Health Literacy and Mortality Among Elderly Persons," Archives of Internal Medicine, Vol. 167, No. 14 (July 2007).

8. Roter, Debra L., et al., "Effectiveness of Interventions to Improve Patient Compliance: A Meta-Analysis," Medical Care, Vol. 36, No. 8 (August 1998).

9. Roughly three-quarters of physicians are in practices that treat patients with at least one of the four focal chronic conditions. Ninety percent of primary care physicians are in practices that treat all of the four conditions.

10. Betancourt, Joseph R., et al., "Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care," Public Health Reports, Vol. 118 (July/August 2003).

11. All six measures are not relevant to all physicians. For example, interpreter services are not relevant to the 3.5 percent 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 conditions they do treat. See Table 2 notes for more information.

12. In addition to practice type and percentage of minority patients, other physician and practice characteristics are associated with adoption of practices to reduce racial and ethnic disparities. Minority -- black and Hispanic -- physicians are more likely to implement each of the tools than white, non-Hispanic physicians. With the exception of receiving patient demographic reports, the 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 minority health training, have IT available to obtain patients' preferred languages, and receive quality reports according to race or ethnicity, while surgeons were more likely to provide interpreters.

13. Au, Melanie, Erin Fries Taylor and Marsha Gold, Improving Access to Language Services in Health Care: A Look at National and State Efforts, Policy Brief, Mathematica Policy Research, Washington, D.C. (April 2009).

Data Source

This Issue Brief presents findings from the HSC 2008 Health Tracking Physician Survey, a nationally representative mail survey of U.S. physicians. The sample of physicians was drawn from the American Medical Association master file and included active, nonfederal, office- and hospital-based physicians providing at least 20 hours per week of direct patient care. Residents and fellows were excluded. The survey includes responses from more than 4,700 physicians and had a 62 percent response rate. Estimates from this survey should not be compared to estimates from HSC's previous Community Tracking Study Physician Surveys because of changes in survey administration mode from telephone to mail, question wording, skip patterns, sample structure and population represented. More detailed information on survey content and methodology can be found at www.hschange.org.

Funding Acknowledgement

This research was funded by the Robert Wood Johnson Foundation.

Sources and Further Reading

AHRQ — National Healthcare Quality and Disparities Reports — The federal National Healthcare Disparities Report, cited in this study, is produced annually by the Agency for Healthcare Research and Quality and documents quality gaps across racial and ethnic groups.

U.S. Census Bureau — American Community Survey — The 2008 American Community Survey data on language spoken at home, directly referenced in this report, is published by the Census Bureau.

CMS — EHR Incentive Programs and Meaningful Use — The Centers for Medicare and Medicaid Services meaningful use guidelines, referenced in this report, incorporated requirements for recording patient demographics including race, ethnicity, and preferred language.

HHS — Limited English Proficiency and Civil Rights — This report references Title VI of the Civil Rights Act and federal requirements for interpreter services. HHS provides guidance on language access obligations for health care providers receiving federal funding.

AMA — Reducing Disparities in Health Care — The American Medical Association's physician survey master file was used to draw this study's sample. The AMA also publishes resources on physician roles in addressing racial and ethnic health disparities.

Robert Wood Johnson Foundation — RWJF funded this research and the HSC Health Tracking Physician Survey used in this analysis.