MANAGED CARE February 2001. ©MediMedia USA
Unintentional bias can be just as damaging as the overt brand, according to the president of the National Medical Association.
Last August, Rodney G. Hood, M.D., was installed as the 101st president of the National Medical Association, which represents more than 25,000 African-American physicians. As president, he will focus on eliminating racial and ethnic health disparities, particularly in the areas of cardiovascular disease, cancer, diabetes mellitus, and HIV/AIDS. A board-certified internist, Hood has been in private medical practice for more than 20 years and is currently managing partner of CareView Medical Group in San Diego. He cofounded and is president of MultiCultural Primary Physician Medical Group, a 300-physician IPA, and founded CompCare, a 7,000-enrollee Medicaid health plan.
In 1973, Hood became one of the first African Americans to graduate from the University of California, San Diego Medical School. Three years later, he was the first African-American postgraduate to complete a residency in internal medicine at UCSD's medical center. Before choosing a medical career, he earned an honors degree from Northeastern University School of Pharmacy in his hometown of Boston, and a graduate degree from the University of California, San Francisco Graduate School of Pharmacology and Toxicology. He spoke recently with Senior Contributing Editor Patrick Mullen.
MANAGED CARE: How does health care in America differ between whites and blacks?
RODNEY HOOD, M.D.: Despite the fact that we've been here for over 300 years, African Americans have some of the worst health statistics of any group in this country. In my opinion, we have a crisis in African-American health. That's why I'm working toward eliminating ethnic health disparities, specifically in African-American communities. Blacks have higher death rates than whites in 14 of the leading 16 causes of death. We've trailed longevity of the white population for centuries, although we made gains this century. But beginning in the 1980s, life expectancy for blacks has decreased a little.
MC: While life expectancy for whites has continued to climb.
HOOD: Correct. There are a number of alarming trends. We've begun to see studies in the New England Journal of Medicine, the National Medical Association Journal and other publications pointing out race-based differences in health outcomes.
MC: As you noted in your inaugural address, there are significant differences in the treatments different racial groups receive. A lower percentage of blacks receive needed surgery for lung cancer than whites. The same is true with kidney transplants and the list goes on.
HOOD: It goes on and on. If you research the literature, you'll find more than 300 articles talking about disparities in health. Folks are just now becoming aware of this, but the literature pointing out differences in black health goes back a hundred years.
MC: What is causing those differences?
HOOD: The reasons include access issues, economic issues, and insurance issues. I read an interesting summary in which the authors estimated that about 38 percent of the disparity between the death rates of African Americans and white Americans is due to access and socioeconomic issues. About 35 percent is due to biological risk issues such as hypertension. That leaves nearly 30 percent "unknown." Data are beginning to supply some of the reasons for the unknown, and I think those reasons are racial bias and institutional racism. When you look at the data, it's hard to ignore the fact that whether it's intentional or unintentional, conscious or subconscious, different decisions are being made for blacks than for the white population.
MC: How can the scope of the problem be more clearly identified so that solutions can be worked on?
HOOD: First you have to begin to make folks aware of this. The first step is education, both for those in health professions and the population in general. A survey by the Kaiser Family Foundation discovered that the majority of whites were not aware that blacks had worse health status.
MC: The majority of blacks were not aware either.
HOOD: That's correct, even though it's surprising. When asked about the impact of racism, twice as many blacks and Hispanics as whites said that racism impacted health care. So there are a lot of misconceptions out there, which creates a need to talk about these issues very honestly. Second, although we can overstudy something, we need to start doing more research to try to measure the problem. Perhaps because our organization is so concerned about these issues, this newly publicized information has started coming out. At the urging of the National Medical Association and Congressman Jessie Jackson Jr., Congress approved a 17-month Institute of Medicine study that is under way. Its purpose is to evaluate potential sources of racial and ethnic disparity in health care, including the role of bias and discrimination. If it's done in an unbiased way, that study will be very important. The other issue is that officials in the health industry really have to look at this topic. They have their head in the sand and don't recognize that there's a problem.
MC: What would be an example?
HOOD: We get a lot of concerns and complaints from African-American physicians who feel that their patients are slowly being siphoned off to other physicians. Many of them feel they're not included in many managed care panels to the level of whites. I think there's some truth to that, although it may vary in different parts of the country. When we asked health plans about that, they said they couldn't tell us because they don't keep those particular statistics.
MC: Plans don't track the race of physicians on their panels. Should they?
HOOD: It's not only important to track the race of physicians, it's important to track the race of patients. Plans do neither. Data show that race is a risk factor. It ties into trying to deliver appropriate medicine.
MC: One result of the emphasis on market-based approaches to care over the last decade has been that groups that are not seen as profitable; underserved populations, inner cities, don't get the same quality of care as other groups. Is that your take on what's happening?
HOOD: I think you're right. Market forces are devastating to the vulnerable population, especially the African-American population. I'm in private practice in San Diego, and California is highly penetrated by managed care. About 50 percent of what I do is administration. I've been CEO of a small Medicaid health plan and I'm president of a multicultural IPA, so I've learned a lot about the industry. The original goal of managed care was to put resources up front in wellness and preventive care, with the hope of saving money in the end. That was great, but clearly that's not what it's about now. Now it's about managing care to increase net revenue rather than managing care to improve quality. That paradigm puts African Americans at higher risk. I'm not sure that the system that existed prior to managed care was great either, based on outcomes. Now we're putting people in a managed care environment, but I don't think there's any good data to say how these individuals are going to do. The primary problem that I see flows from the emphasis on the bottom line rather than quality care. Also, problems that some people have when trying to negotiate the administrative obstacles of the managed care system put them at a much higher risk.
MC: The NMA supports universal coverage through a single-payer system. Why?
HOOD: We absolutely have to have some kind of system with universal coverage. We have to start there. The NMA is on record as favoring a one-payer system, while the AMA and other folks in the medical community oppose it. But remember, back in 1964 and 1965, the NMA was the only organized medical group that supported Medicare and Medicaid. The AMA totally opposed it because it viewed it as socialized medicine. Today, most members of the AMA would not be able to exist without those two programs. Even some type of universal system that gave access to all patients would not solve the problem. Even with access, the data show that there are differences in care. We would have to make sure that once access was achieved, there was culturally appropriate care free of racial bias.
MC: How would culturally appropriate care differ from the care African Americans receive today?
HOOD: One way you can achieve culturally appropriate care is to bring back choice. Patients need to be able to choose their physician, and physicians need to have access to those patients who want to choose them. A study of mostly African-American patients at John Hopkins showed that many of these patients felt more comfortable going to a provider of a similar ethnic background.
MC: That would seem to be self-evident. No one is surprised by the fact that many women prefer to have a female OBG.
HOOD: I agree. I don't think it should be surprising at all. However, because of the way the system is set up, it's not happening. Thirty years ago, African-American physicians treated more than 90 percent of African Americans. Today, white physicians treat two thirds of the African-American population. Some of that is by choice, but a lot of it has to do with the African-American population being disenfranchised from African- American physicians. I've been in practice for over 20 years, and I can't tell you the number of patients who wanted to choose me but couldn't because I wasn't part of the health plan that covered them. They tell me that they'd prefer being treated by me but have to go elsewhere, usually to a larger group that may or may not have a physician that looks like them.
MC: Is it possible to quantify the impact of racial bias in health care?
HOOD: First, we need to recognize that indeed racial bias and institutional racism do exist in our country as well as in America's health system. It has not really been measured and may not even be conscious. Just as health plans have quality indicators for such things as the number of mammograms or pap smears, they need to develop quality indicators to monitor racial bias, and to tie that to outcomes. Once those in the industry recognize that there's a problem and that they can measure it, they need to develop a strategy to eliminate this problem.
MC: Is medicine in particular or health care in general any more or less racist than the rest of American society?
HOOD: I don't think they're any more racist. I just think that they're more in denial. Physicians are taught that we're treating a human being and that we're supposed to put our biases aside and make the best medical decision for the patient. Many of us try to do that and believe that; but the truth is that's very difficult to do. There's this huge and maybe false medical ethic that says it's unethical to show a bias. It's an area that's been hard to penetrate. Most physicians, whether they're white or black, mean well and want to do the best thing for the patient. But evidence suggests that they are bringing their biases to the table. My concern, to be blunt, is that it's killing patients. While racism in health care is just like racism in the general community, it's been talked about less in medicine. We've heard about it in the work force and in cases of police brutality. You see that all the time. Very seldom do you hear it being talked about in health care. People who do talk about it in health care use sanitized words like race-based differences instead of calling it what it is: institutionalized racism.
MC: What strategies are most effective in helping your white counterparts become more conscious of that fact?
HOOD: It's an educational process. It's important that as an African American, I bring up the issue in a nonthreatening way and put it in a historical light. This is not an African-American problem. Unless we see it as an American problem, I don't think we're going to solve it. I give a series of talks on origins of racism in medicine, using an excellent book that just came out, An American Health Dilemma: A Medical History of African Americans and the Problem of Race. I've read this book twice, and I use a lot of information in there to outline the historical health experience of African Americans. When you look at that history, you see where the health profession actually taught that blacks could tolerate pain much more than whites. That was taught by well-meaning white physicians centuries ago. As recently as 1970, it was taught that blacks did not have heart attacks. It was not until the 1970s that we had data showing that not only do blacks have heart attacks, but also that they have them at a higher rate than whites. How physicians diagnosed or treated their chest pain before that, I don't know.
MC: Has managed care turned the corner yet in terms of returning clinical authority to physicians?
HOOD: We have a long way to go. Over the last decade I've seen a significant disenfranchisement of physicians from patients, not just in African Americans, but in general. It's been done in a sinister way. When I want to prescribe X drug or X therapy, I put in a request and the patient is turned down. My patient is told that I prescribed a drug that's not covered, so it's my fault. Or a plan will tell the patient that he can't have an MRI scan because he didn't get appropriate documentation from the doctor. It's always made to look like it's the doctor's fault. Doctors end up spending a lot of time trying to explain and navigate the system. Managed care has all these unfair and unnecessary obstacles that are put there to prevent access. This makes the African-American community much more vulnerable, because I don't think blacks navigate the system as well as whites do. Blacks may get into a managed care system that quotes quality indicators showing how well they're doing as a system. But they're not monitoring race and ethnicity. Maybe they have 98 percent overall compliance on a given measure, but only 70 percent or 80 percent in the African-American community.
MC: How will things change as the racial mix in the United States evolves and our population becomes less white? Won't we reach a point at which there are so many nonwhite people that these issues cannot be ignored?
HOOD: To a certain extent that's true. That demographic change is going to force us to begin to address this issue. My concern is that while the numbers are changing, that doesn't guarantee the system will change. Go back to the African-American experience down South after slavery. During Reconstruction, there was a period of 10 to 15 years when blacks were given freedom. They elected black senators and congressman. Their numbers were greater in many areas than whites, so blacks felt that eventually they would be empowered. The people in power felt so threatened that they changed the system to disenfranchise the people who were in higher numbers.
MC: That change was part of the deal that decided the 1876 presidential election, the most unsettled in our history until the 2000 election.
HOOD: Yes, as I recall, the election of 1876 was similar to the split between the Electoral College and the popular votes with Florida as the key state. However, that election turned out to be devastating for the health and freedom of the recently freed slaves. The winner of that presidential election struck a compromise with the southern states not to enforce the laws of the Constitution or those enacted with Reconstruction. If you look at our current split, we have a class divide in this country. African Americans, other minorities, lower-income working people went strongly for Democrats. On the other side you had the upper middle class and white males. Democracy is wonderful, but this election tells us that we have huge differences in this democracy. We need to start talking about what they are, so that we can understand the issues on both sides without hollering at each other.
MC: Are we mature enough as a people to do that?
HOOD: I think we are. I find that the thing that really stimulates folks to make changes in this country is money. For this country to continue its economic growth, businesses will have to recognize the demographic shifts toward minorities because that's where their growth will come from. It's the same thing in the health industry, where managed care has ignored many of the minority populations for years. That's going to be an area of growth. Ultimately, some form of universal care will come. When that comes and even the underserved vulnerable populations have adequate coverage, health care providers will look to those populations to grow their market share. So economics will force some of the change that we're going to see take place.
MC: How soon might universal coverage be achieved?
HOOD: I'm not sure. Although our organization is for full universal access and single payer, the AMA is not. It's for improved quality but it's still fighting to hold onto the fragmented system. Things are starting to change. Even the AMA is talking about how it can reorganize itself. I would guess that less than 10 years would be optimistic, and between 10 and 20 years probably is realistic.
MC: Will change be driven by consensus about how a new system should work or by desperation that what we've got doesn't work?
HOOD: Both. That's just the history of this country. Sometimes we have to be forced to change.
MC: Thank you.