Healthcare Inequities Are Costly to Patients and Financials – And There Are Practical Ways to Stop the Suffering

A devastating blind spot among health care professionals is the unintentional biases that exist when treating patients from marginalized populations. The inability to connect with these patients has created communication barriers between caregiver and patient and a lack of trust, which are essential to improving their care and overall wellbeing.

By definition, the disparities happen precisely because of the very differences that people manifest based on their biology, their cultural values, their socioeconomic status, and the impact on them of conscious and unconscious biases in society at large and within the healthcare system itself.?

Over the past ten years of leading the patient experience in large strategic health systems, I have seen various approaches that do not improve the patient experience across culturally diverse groups.??For many in healthcare there is not even awareness that there are disparities. But even among those where there is awareness, healthcare practitioners tend to use monocultural methods to address a multiplicity of differences across race, ethnicity, gender, and sexual orientation lines.?

This leads to eroded trust on the part of patients in healthcare professionals and the systems in which they function. Studies have shown that empathy has a profound effect on making a patient feel cared for and heard, which is most important to improving their experience of care and gaining patient trust.??The relationship between healthcare worker and patient is fiduciary in nature, meaning it is based on trust. Without it, it leads to less effective treatment and even greater number of deaths.

Patients who do not believe their interests and needs are valued have lower levels of trust in the caregiver, leading to decreased patient compliance and adverse outcomes.??

From a diversity perspective, unconscious bias and explicit racism can be further corrosive to the patient/healthcare worker relationship.??Patients who do not believe their interests and needs are valued have lower levels of trust in the caregiver, leading to decreased patient compliance and adverse outcomes.??This not only has human quality of life impact it also has a financial cost to the healthcare system.?

Human Cost

The uniqueness of demographic groups requires varying approaches to communication.??Racism can impede intercultural communication and active listening.??While healthcare providers may not purposefully communicate in a manner that restricts the ability to understand others, unconscious bias and personal stereotyping diminishes the ability to listen actively and/or ethically. Respect and empathy are critical components to human connection, and they are essential to building trust.??

Laura Bogart, Ph.D., a social psychologist, and senior behavioral scientist at the RAND Corporation defines medical mistrust as an absence of trust that health care providers and organizations genuinely care for patient’ interest, are honest, practice confidentiality, and have the competence to produce the best possible results.??

Within the African American community, mistreatment and dehumanizing care has seriously affected trust between patient and caregiver.??According to a study published in the Proceedings of the National Academies of Science (2016), 40% of first and second-year medical students endorsed the belief that “black people’s skin is thicker than white people.”??These types of stereotypes lead to disparities in pain management even today.

Mistrust in healthcare is not just rooted in past legacies, but also arise from current day inequities in access to care, substandard health facilities in minority neighborhoods, differences in treatment plans for white patients vs. minority patients.??

In a study of 10,144 female patients with a breast cancer diagnosis, black patients had a significantly lower mean score in patient surveys from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for getting care quickly, getting needed care, getting needed prescription drugs, and lower ratings of their healthcare compared to white patients (Farias et. al, 2019).??In addition, Black and Hispanic women had a 2.5- and 1.5-times greater odds of presenting with advanced disease and are more likely to die from the disease.??According to Farias et. al (2019), these disparities are also reported among patients with other chronic diseases.??

Black and Hispanic patients are less likely to report excellent provider communication and care coordination among specialist providers as compared to non-Hispanic white patients.

Racial and ethnic minorities are not the only ones receiving inequitable treatment. Despite existing protections offered in Section 1557 of the Affordable Care Act, LGBTQ (Lesbian, Gay, Bisexual, Transgender, and Queer) people continue to face significant rates of discrimination (Mirza & Rooney, 2018).??In 2016, the LGBTQ+ community was identified by the National Institute on Minority Health and Health Disparities as a health disparity population. In 2017, the Center for American Progress published a national representative survey of LGBTQ people and found that 3 in 10 transgender people report that healthcare providers would not see them because of their gender identity.

The What We Know Project at Cornell University conducted a systematic literature review of all peer-reviewed articles in English before 2018 that assessed the effect of discrimination on the Health of LGBT people in the US. Of the 300 identified studies, they found 82% (245) studies found robust evidence that discrimination on the basis of sexual orientation or gender identity adversely impacts the health of LGBT people.

In 2015, the U.S. Transgender Survey found 1 in 4 transgender people had avoided seeking healthcare for fear of discrimination.

Financial Cost

Through disparate treatment, not only do patients suffer, but also so does the financial health of healthcare organizations. Inadequately addressing the needs of diverse patient populations can have serious financial implications.??

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures patients’ perceptions of their hospital experience.??The HCAHPS puts financial pressure on hospitals because they must score in the top half of all facilities to avoid losing income.??The Affordable Care Act has mandated that up to 2% of Medicare inpatient payments be withheld from hospitals if they fail to score in the top half in the following areas:

• Clinical process of care
• Patient experience of care
• Outcomes of care
• Efficiency

How to Respond?

How to turn the tide on these trends? Annual courses related to DE&I alone will not produce a change.??Neither do superficial short-term DE&I interventions change human behavior. As complex and pervasive as these issues are, there are proven and practical interventions to bridge the gaps that will both improve the health of patients being hurt by these disparities and, in that, improve the financial outlook of healthcare organizations.

Here are key steps healthcare organizations can take for interventions that will make a difference:

1. DE&I scenario-based crosscultural competence training must be built into broader programs. These programs could include purposeful rounding, discharge instruction, and medication education programs that are already in place.??
2. Inclusive leaders are needed to tackle these realities. Inclusive leader assessment and coaching combined with leadership development workshops can equip leaders with the communication and culture transformation skills necessary to coach and hold accountable healthcare workers toward more inclusive patient care that will reduce inequities.?
3. Create a clear DEI business strategy that includes patient experience with measurable goals to track progress.??In many cases DEI is seen as a Human Resources initiative; therefore, the responsibility is within the HR Department.??If this is the case, a DEI Committee that includes the Chief Patient Experience Officer will be critical to furthering the patient experience commitment to DEI, because they often have first line communication to patients and their families as well as ownership of the patient experience data.
4. Health systems must measure their progress.??The first step is to capture the baseline of where the organization sits.??One method is to segment patient survey data to better understand the experience by race, gender, sexual orientation, and age.??In addition, patient complaints and grievances can be utilized.??Data collection will allow the organization to capture ad hoc information on patients’ experiences that can be used in planning.

The recognition that disparities are real and systematically consistent is a start. It must follow with an admittance that the existence of these healthcare inequities is a dereliction of the duty to do no harm that must be treated as one of the most urgent issues the healthcare system must address.?

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References

What does the scholarly research say about the effects of discrimination on the health of LGBT people? Cornell University. Center for the Study of Inequity. www.whatweknow.inequity.cornell.edu. Retrieved January 6, 2023.

Farias, A. et. al (2019). “Racial/ ethnic differences in patient experiences with health care in association with earlier stage breast cancer diagnosis: findings from the SEER-CAHPS data.” HHS Public Access. Doi: 10.1007/s10552-019-01254-3

Gillespie, C. (2022). 7 Major Health Disparities Affecting the LGBTQ+ Community. www.health.com. Retrieved January 5, 2023.

Hostetter, M., & Klien, S., (2021). “Understanding and ameliorating medical mistrust among black Americans.”?Transforming Care?(newsletter), Commonwealth Fund.?https://doi.org/10.26099/9grt-2b21

Mirza, S. & Rooney, C., “Discrimination prevents LGBTQ people from accessing health care.” January 18, 2018. www.americanprogress.org