Combating Racial Bias - A Priority for Payers

As Minority Health Awareness Month draws to a close, and I wanted to share a bit about what this means to me personally and give you an example of why it’s important we focus on this.

When I was a resident working in the emergency room, I frequently noticed that African American patients were disproportionately represented among the patients, and particularly among those who were in the locked unit without an individual room (indicating that they may become “violent”). There were rarely as many white people in a locked unit.

 This difference in the standard of treatment led me to pursue a quality improvement project utilizing standardized violence risk assessment as a requirement for patient assessment. In completing the project, our team found that the use of the locked unit and forced medications were significantly higher in African American patients.

To my knowledge, none of the providers or nurses who worked in the emergency room used racial slurs or consciously endorsed feelings of racial hatred towards their African American patients. And yet the pattern of treating these patients differently was evident, from the data we collected in our study.

 Later I had the opportunity to participate in a work group on implicit bias that helped to clarify the unconscious prejudices that may cause physicians and other healthcare providers to treat patients differently based on race. Many studies have identified that implicit bias plays a role in the way that medical treatment is delivered[i][ii], and these have concluded that “most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color”.[iii]The cumulative impact of individual acts of bias and structural racism have led to unacceptable disparities in behavioral health care between white and non-white Americans.[iv]At its heart, unconscious bias is a mental short cut that we use more readily when in a rush or under pressure. The time pressures and high patient volumes of the emergency room make it a setting where providers are more likely to jump to conclusions with limited evidence in the interest of efficiency.[v]

 Across populations, we know that diminished access to healthcare services leads to later diagnosis and that these delays in diagnosis can lead to more severe illness. Behavioral health disorders are no exception to this rule. African Americans, Hispanics and Asian Americans are significantly less likely to receive a diagnosis of depression from a health care provider when compared to non-Hispanic whites.[vi] Delayed diagnosis leads to delays in care, often resulting in minority patients presenting to the emergency room in crisis. And potentially to a locked unit, going back to my earlier example.

In my own clinical experience, I have found that the implicit bias of providers can be frankly traumatic for patients of color and can lead them to avoid seeking behavioral health care. One man, who had been led through the ER in handcuffs after suffering a psychotic break, wept openly as he told me how humiliating he found the experience. He kept repeating, “I didn’t do anything wrong” and convincing him to accept admission to the hospital when he once again became ill was very difficult.

 Unfortunately, children are not exempt from the impacts of implicit bias. African American and Hispanic children remain persistently less likely to receive any mental health care, any outpatient care, and any medication initiation for mental health diagnoses.[vii]Unsurprisingly, leaving childhood mental illness untreated has significant developmental implications across the lifespan.

 We can change disparities in mental health access, and this will change outcomes. There are also tremendous financial benefits to eliminating disparities in medical care – research suggests that this may be as high as $1 billion nationwide largely through decreases in emergency room and inpatient utilization.[viii]

 Anti-bias training for healthcare workers, as well as holding healthcare systems financially accountable for health disparities as part of an overall focus on quality and value have promise as strategies to transform the healthcare experiences of minority patients. Implicit bias leading to racially disparate outcomes in medicine is a public health crisis and should be treated as such. The path to true healthcare quality must begin by prioritizing equality for all patients.

 [i] Maina, I. W., Belton, T. D., Ginzberg, S., Singh, A., & Johnson, T. J. (2018). A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social science & medicine (1982), 199, 219–229. https://doi.org/10.1016/j.socscimed.2017.05.009

[ii][ii] Dehon, E., Weiss, N., Jones, J., Faulconer, W., Hinton, E., & Sterling, S. (2017). A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 24(8), 895–904.

[iii] Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American journal of public health, 105(12), e60–e76. https://doi.org/10.2105/AJPH.2015.302903

[iv] Johnson T. J. (2020). Racial Bias and Its Impact on Children and Adolescents. Pediatric clinics of North America, 67(2), 425–436. https://doi.org/10.1016/j.pcl.2019.12.011

[v] Johnson, T. J., Hickey, R. W., Switzer, G. E., Miller, E., Winger, D. G., Nguyen, M., Saladino, R. A., & Hausmann, L. R. (2016). The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 23(3), 297–305. https://doi.org/10.1111/acem.12901

[vi] Shao, Z., Richie, W. D., & Bailey, R. K. (2016). Racial and Ethnic Disparity in Major Depressive Disorder. Journal of racial and ethnic health disparities, 3(4), 692–705. https://doi.org/10.1007/s40615-015-0188-6

[vii]Lê Cook, B., Barry, C. L., & Busch, S. H. (2013). Racial/ethnic disparity trends in children's mental health care access and expenditures from 2002 to 2007. Health services research, 48(1), 129–149. https://doi.org/10.1111/j.1475-6773.2012.01439.x

[viii] Cook, B. L., Liu, Z., Lessios, A. S., Loder, S., & McGuire, T. (2015). The costs and benefits of reducing racial-ethnic disparities in mental health care. Psychiatric services (Washington, D.C.), 66(4), 389–396. https://doi.org/10.1176/appi.ps.201400070