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	Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care? Journal Article

Racial and Ethnic Disparities Linked to Physician Practice Resources

Physicians Treating More Minority Patients Report Greater Problems Delivering High-Quality Care; Increasing Medicaid Payments to Medicare levels Could Reduce Health Care Disparities

News Release
April 22, 2008

FURTHER INFORMATION, CONTACT:
Alwyn Cassil (202) 264-3484 or acassil@hschange.org

WASHINGTON, DC—Primary care physicians treating a disproportionate share of black and Latino patients typically earn less, see more patients, provide more charity care, treat more Medicaid patients and receive lower private insurance payments, according to a national study funded by the Commonwealth Fund and published today as a Web Exclusive in the journal Health Affairs.

These same physicians also reported more problems providing high-quality care, ranging from inadequate time with their patients to difficulty obtaining specialty care. Conducted by researchers at the Center for Studying Health System Change (HSC), the study sheds new light on the pervasive racial and ethnic health disparities in the United States by looking beyond individual patient characteristics to community and physician practice resources. The study also examined how higher Medicaid payments might help physicians treating mostly minority patients provide high-quality care and reduce racial and ethnic disparities.

"The findings indicate that the lower resources flowing to physicians treating more minority patients are associated with racial and ethnic disparities," said HSC Senior Researcher James D. Reschovsky, Ph.D., coauthor of the study with HSC Senior Researcher Ann S. O’Malley, M.D., M.P.H.

"Raising Medicaid payment rates, along with efforts to increase insurance coverage or otherwise increase resources flowing to physicians treating low-income and minority patients could reduce disparities," Reschovsky said.

"The findings indicate that physicians who treat mostly minorities face challenges in delivering high-quality care. However, it also points to solutions that can reduce racial and ethnic disparities while improving health care access, quality and efficiency for everyone," Commonwealth Fund Assistant Vice President Anne C. Beal, M.D., said. "In addition to increasing Medicaid payment levels, other efforts such as quality reporting and financial incentives for improving care, particularly through Medicaid, could also reduce disparities and help move the U.S. toward a high performance health system."

The Health Affairs article, titled "Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?" is based on findings from HSC’s nationally representative 2004-05 Community Tracking Study Physician Survey, supplemented by secondary information from the Census Bureau and other sources. The survey had a 52 percent response rate and included information from 3,320 primary care physicians—general internists, family/general practitioners and pediatricians.

The researchers first identified physicians in low-, medium- and high-minority practices—those whose patient panels were less than 30 percent, 30-70 percent, and greater than 70 percent black or Latino, respectively.

About 52 percent of primary care physicians reported having patient panels with less than 30 percent minorities, 36 percent reported 30-70 percent of their patients were minorities, and 12 percent reported minorities constituted more than 70 percent of their patients, confirming previous research showing that relatively small numbers of physicians treat a disproportionately large share of minority patients.

The study also confirmed previous research showing well-established associations among greater minority presence, less insurance coverage and lower incomes. In 2004-05, physicians in high-minority practices were located in areas with lower median incomes and higher uninsurance rates, according to the study.

Moreover, physicians in high-minority practices received more than a third of their practice revenue from Medicaid, compared with 13 percent for physicians in low-minority practices. The study also found that 35 percent of physicians in high-minority practices reported patients’ inability to pay was a major barrier to providing high-quality care, compared with 23 percent of physicians in low-minority practices.

Other key study findings include:

• Twenty-six percent of physicians in high-minority practices reported being unable to provide high-quality care to all of their patients, compared with 16 percent of physicians in low-minority practices.
• Physicians in high-minority practices reported caring for more patients with whom they had a hard time communicating because they speak a different language—8 percent of patients in high-minority practices vs. 2 percent of patients in low-minority practices.
• International medical graduates were nearly twice as likely to be found in high-minority practices-nearly 40 percent vs. 21 percent in low-minority practices. Physicians in high-minority practices had fewer years of practice experience (14 years vs. 17 years) and were less likely to be board certified than their counterparts in low-minority practices (80% vs. 89%).
• Physicians in high-minority practices were more likely to report difficulties obtaining specialty care for their patients (42%), compared with physicians in low-minority practices (31%). The physicians attributed this to patients being uninsured or having insurance coverage that posed access barriers-not to an inadequate supply of qualified specialists in the area.
• Physicians in high-minority practices reported inadequate time during office visits was a major problem affecting their ability to provide high-quality care—26 percent vs. 18 percent of physicians in low-minority practices. Physicians in high-minority practices spent about 30 percent less time with each patient seen than those in low-minority practices (15 minutes vs. 21 minutes).
• When researchers modeled the likely effect of raising Medicaid physician payments to equal Medicare payments, they found improvements on several measures, particularly for physicians with high-minority practices. For example, inadequate time with patients was reduced by 5.8 percentage points among physicians treating high proportions of minority patients.
• Physicians in high-minority practices were significantly more likely to report difficulties obtaining timely reports from other providers than physicians in low-minority practices. Nearly a quarter of physicians in high-minority practices reported that not getting timely reports from other providers was a major problem affecting their ability to provide quality care, compared with 11 percent of physicians in low-minority practices, suggesting increased challenges to care coordination for providers in high-minority practices.
• Similarly, physicians in high-minority practices were 10 percentage points more likely to complain that the scope of care they are expected to provide without referral was greater than it should be (28% vs. 18% in low-minority practices).

The study concludes that "racial and ethnic disparities in primary health care are in part systemic in nature, and the lower resources flowing to physicians treating more minority patients are a contributing factor. In particular…if Medicaid payments to physicians were on par with those paid by Medicare, disparities in reported difficulties between physicians whose patient panels were made up of greater versus. smaller proportions of minorities would diminish, often substantially. Low payments may be leading primary care physicians to reduce the time spent with patients and more generally diminish their ability to function effectively as their patients’ medical home."

The Commonwealth Fund is an independent foundation working toward health policy reform and a high performance health system.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.