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Marsha Lillie-Blanton, Rose Marie
Martinez, and Alina Salganicoff
excerpted from: Marsha Lillie-Blanton, Rose Marie
Martinez, and Alina Salganicoff, ,Site of Medical Care: Do Racial And
Ethnic Differences Persist?, 1 Yale Journal of Health Policy, Law &
Ethics 15 (Spring 2001)(26 Footnotes Omitted)
Prior to the 1960s, Americans generally obtained health care in
racially segregated facilities or from health providers of their own
race or ethnicity. Racial, geographic, and economic factors influenced
where minority Americans could get their health care. Minority
Americans, who were disproportionately low income, relied on a
combination of sources of care, such as public hospitals and private
charity care, because they were unable to afford the cost of a private
doctor. Even middle-income minority Americans largely relied upon
racially segregated sources of care because these were the only options
available to them.
In the past four decades, substantial progress has been made in
reducing differences in the major sources of health care used by whites
and blacks, as well as other racial/ethnic minority groups. Nonetheless,
striking racial/ethnic disparities in health care use and health
outcomes persist. While these disparities are well documented, factors
underlying these differences are not well understood. The most
frequently advanced explanations for current health care disparities
focus on the characteristics of the patient (e.g., economic conditions
or preferences) or the individual provider (e.g., competence or biases).
However, it is conceivable that differences in the primary sources of
care used by white patients and minority patients might explain some
variations in the content of care. Structural or institutional
factors--patient-provider relationships, referral networks, and the
availability of resources such as highly trained staff and
state-of-the-art technology--of varying sources of care may influence
the care that patients obtain. Improving knowledge of the extent to
which racial/ethnic differences persist in the site of medical care will
inform future investigations of the causes of health care disparities.
This study, based on original research, examines whether the major
sources of ambulatory medical care of whites, African Americans, and
Latinos, given similar insurance coverage, differ substantially in the
United States. The intent of the study is to assess whether, at the
start of the twenty-first century, race/ethnicity continues to be a
primary determinant of where medical care is obtained.
. . .
This study examines the progress achieved in reducing the racial
divides in one of many possible indicators of health care access--the
site of medical care. The study provides evidence that the vast majority
of Americans, regardless of race/ethnicity, currently identify an
office-based setting as a regular source of care. Moreover, only a small
fraction of Americans rely on a hospital ER as a regular source of care.
However, African Americans and Latinos, regardless of insurance status,
continue to be far more reliant than whites on what some consider to be
"non-mainstream" sources of care, with African Americans and
Latinos being about twice as likely as whites to rely on a
hospital-based provider as a regular source of care. The uninsured also
were more likely than the insured to rely on a hospital-based provider
as a regular source of care.
While the finding regarding the uninsured is consistent with other
research, the continuing role of race/ethnicity as a factor associated
with where an individual obtains health care was a less predictable
finding. Studies in the 1980s had shown that minority Americans were
more likely to use community or hospital-based clinics, but these
studies left unanswered whether utilization patterns were a function of
racial/ethnic differences in insurance coverage or income. This study
provides strong evidence that race--independent of insurance coverage
and income--continues to be associated with where ambulatory health care
is obtained. The study findings counter the perception that whites,
African Americans, and Latinos obtain health care from the same types of
providers. While that fact is true for the vast majority of the
population, there is a sizable subset of African Americans and Latinos
who show a pattern of accessing the health care system that is different
from the patterns observed in most Americans.
These findings are consistent with those of a recent study by Gaskin,
which examines use patterns of inpatient hospital care. Analyzing 1994
hospital discharge data from nine states, Gaskin found that residents of
racial and ethnic minority neighborhoods were more likely than the
general population to use public hospitals and major teaching hospitals.
Taken together, the findings provide evidence that racial/ethnic
background continues to shape choices regarding the site of medical
care. It also is conceivable that the findings may understate racial
differences in the sites of medical care since respondents who identify
community health clinics (private or public) as a regular source of care
are defined as having an office-based provider.
As previously noted, structural or institutional factors of varying
settings of care may affect the content of care. These factors may
explain some of the racial/ethnic differentials in care that have been
observed. Research has shown that the organizational setting of care can
affect the cost, quality, and patient satisfaction associated with care.
Other factors, however, such as an individual's health and social needs,
should also be considered in evaluating the content and appropriateness
of care provided by a health care setting. A physician's office, for
example, may be more conducive to a satisfying doctor-patient
relationship but less convenient for some diagnostic tests. A
hospital-based outpatient clinic might provide more technically
sophisticated care than a physician's office but may have less potential
for the development of a strong provider-patient relationship. Questions
about differences in the quality of care in various settings, including
various types of office-based settings, deserve to be systematically
explored in future research and the findings included in the dialogue on
possible factors contributing to racial/ethnic differences in health
care.
This study raises a number of other issues for further investigation.
Perhaps most important among these issues is the question of what
factors explain the effect that race/ethnicity continues to have on
where an individual obtains health care. Race/ethnicity might be a proxy
for any number of factors such as the availability of private physicians
in minority communities, patterns of residential segregation, or
financial barriers such as co-payment requirements. It also might
reflect preferences of patients for the flexible hours or other
conveniences of hospital-based sources of care, a possibility consistent
with the findings of a study that compared the characteristics of
regular users of hospital OPDs and regular users of private physicians.
The findings also might reflect historical patterns of utilization or
choices made by patients because some sources of care may be perceived
as more welcoming or culturally competent. These two factors may be
linked since an individual may initially choose a source of care based
on family tradition, but is unlikely to remain with that source of care
solely for that reason. In sum, the finding could reflect barriers to
care, patient preferences, or, of course, some combination of these
factors.
The finding that race/ethnicity continues to exert strong influences
on where individuals receive health care raises a multitude of
questions. Further work is needed to explore the incentives and
disincentives for obtaining care from different sites. It also will be
important to assess whether there are systematic differences among the
different sites in the content of care or the patient-provider
relationship (e.g., communications and trust), and whether these
differences have implications for the health care outcomes of African
Americans and Latinos. |
