Race, Health Care and the Law 
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Site of Medical Care: Do Racial And Ethnic Differences Persist?

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Vernellia R. Randall
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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.

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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu


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