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U.S. Health Care: Separate and Unequal

A large survey of U.S. primary care physicians uncovered differences between those who see many black patients and those who see few.

In the U.S., black patients generally receive lower-quality health care than do white patients. Racial disparities in health care often are ascribed to patient characteristics, such as economic or educational status, or to elements of the doctor-patient relationship, such as cross-cultural communication and sensitivity. To what extent can racial disparities in health care be attributed to the characteristics of physicians and their access to resources?

Researchers linked 2000-2001 survey data from 4355 primary care physicians with claims data on 150,391 visits of Medicare patients to these physicians. Care for black patients was concentrated within a relatively small group of physicians: 22% of doctors provided 80% of care for black patients. Black patients were much more likely than white patients to be treated by black physicians, and racial concordance between patient and physician was stronger than would be predicted by geographic distribution of physicians and patients alone. Regardless of their race, physicians who treated many black patients were significantly different from those who saw few black patients: They were less likely to be board certified, and were more likely to report being unable to provide high-quality care to all patients and having limited access to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admissions. Access to care was determined more strongly by geography than by individual doctor; little variation occurred in access to resources among doctors within the same geographic area.

Comment: Without negating the effects of patient and interpersonal variables, these researchers identify geographic and structural factors that also contribute to racial disparities in health care. In an accompanying article, an editorialist explores possible approaches to ameliorating these differences.

— Bruce Soloway, MD

Published in Journal Watch General Medicine August 20, 2004

Citation(s):

Bach PB et al. Primary care physicians who treat blacks and whites. N Engl J Med 2004 Aug 5; 351:575-84.

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• Medline abstract (Free)

Epstein AM. Health care in America -- Still too separate, not yet equal. N Engl J Med 2004 Aug 5; 351:603-5.

• Original article (Subscription may be required)
• Medline abstract (Free)