When Dr. Joseph Betancourt spoke on “Solutions for Disparities: Delivering Quality Care to Diverse Populations” in Chattanooga TN, he delivered both unusual expertise and a personal model for future healthcare. Dr. Betancourt’s family came from Puerto Rico to NYC and he talked about his childhood as interpreter for his grandparents to their doctors. Today, Dr. Betancourt is Director of the Disparities Solution Center and Senior Scientist at the Institute for Health Policy at Massachusetts General Hospital. With his medical degree, fellowship in Minority Health Policy and Masters from the Harvard School of Public Health, Dr. Betancourt is now a well-respected expert in cross-cultural medicine.
Dr. Betancourt presentation was sponsored by Erlanger Health System and Merck and was attended by healthcare educators, administrators, community advocates, business leaders and elected officials. He began his discussion of minorities and healthcare access, provision and outcomes, by citing a recent survey showing that it’s still a common practice for immigrant families to use a child as an interpreter. He shared that, “Some people think if they just speak slowly and loudly, it’s working.” Language is a huge barrier and quality care cannot be assumed. Just because the patient says ‘Yes, doctor’ doesn’t mean agreement or even understanding. The doctor is an authority figure in this culture and will not get a ‘no’ response. “All the science in the world is worth nothing if the patient is not in sync culturally with the doctor and won’t do what is suggested.”
The discussion expanded from the personal anecdotes to address the major elements of healthcare disparities in the United States: Health Outcomes and Healthcare Access & Provision.
- Despite a lower incidence rate, African-American women are more likely to die from breast cancer than their white counterparts. • Infant mortality rate are 2.5 times greater for African-Americans than non-Hispanic whites even when socioeconomic status is relatively equal.
- Outcome comparison on Diabetes death rate : White 22.8% , Black 50% , Hispanic 33.6% , Native American 50.3%, Asian 18.4%
- Social and geographic determinants are key factors of outcomes: Poverty • Environmental toxicity • Less education • Less access to fresh food
Dr. Betancourt was careful to note that there is diversity within each culture. The example he cited was asthma, an epidemic among Hispanics but occurs 8 times more frequently in the Puerto Rican than Mexican community. In New York City North of 96th Street, asthma is about 9 times more prevalent than below 96th Street because of old housing, old buses. This is a Puerto Rican neighborhood and an example of how culture, geography and poverty shape healthcare needs.
ACCESS & PROVISION:
Whatever the needs, differences in healthcare access and provision are visible even in the same location with the same insurance. The color of a patient’s skin may determine the quality and speed of procedures, the amount of pain medication.
Research shows that equity is compromised by:
• Healthcare providers are less likely to discuss treatment with minority patients.
• Minorities report more difficulty communicating with their doctors.
Why We Should Care: From 1999-2002, a Congressional committee studied the disparities of racial and ethnic patients. The research showed that in addition to communication issues, 50% of racial and ethnic patients experienced stereotyping while 60% expect to experience it in the future. Dr. Betancourt stressed that equity in healthcare access and provision involves us all. The American public should understand that the combined direct and indirect disparities cost from 2003-2006 was 1.24 trillion dollars.
Medical errors, timeliness, efficiency and quality of treatment issues resulted in:
• Longer, costly stays in hospitals • Re-admission within 30 days more likely • More tests due to communication errors • A life time of mistrust leading to end-of-life choices that can be more painful and costly.
SOLUTIONS: What We Can Do
Congress is considering ways to address the situation but funding is lacking and lobbying for support should be a community priority. In the meantime Dr. Betancourt supported more research and urged hospitals collect data on quality of care and outcomes for minorities. He noted that were several ongoing studies looking at healthcare by race and ethnicity in areas such as depression, heart failure and cause for re-admission. He underscored the necessity of addressing depression given that 50% of individuals have had depression in the last few years. “Don’t leave mental health issues out of this puzzle. They can’t focus on self-care otherwise. “
Dr. Betancourt noted that his own program is taking on issues such as management of diabetes and colon cancer screening. However, funding and trained personnel are vital to create equitable solutions across communities.
Some of the solutions he recommended included:
• Healthcare coaches: Assist around chronic disease management. Medical schools are not very diverse. African American males are rare. Maybe community coaching is an area for more diversity in the healthcare field.
• Healthcare Navigator: Help patients with abnormal tests to prevent advancement of disease including a list of all those overdue or need chaperone
• Community Healthcare: Increase workers based in community who can visit homes and assist chronic disease management.
• Education for Providers: Implement case-based e-learning that is relevant to specific cultural groups rather than based on the ‘typical’ vs. ‘a-typical’ model. Teach every detail about communication, clinical issues and barriers to successful care.
• Resources for hospitals that are major resources in the minority communities: Provide more resources whether through foundations or otherwise to better equip the hospitals for that role.
• Multi-discipline teams: Bridge the gap between health care providers and patients. Include translators and translating technology to assist with communication. (Support ESL education for the community.)
• Cultural Competence: Expand the number and kind of medical personnel who receive cultural competence training and include factors such as age and gender. Dr. Betancourt shared that cultural competence may reveal surprising information, and noted that the most underserved population may be whites in trailer parks.
Dr. Betancourt took questions from the diverse audience in a lively exchange of challenges and solutions. His philosophy in responding to these questions can be summed up in this quote envisioning our future
“… society whose core values include equality of opportunity, justice and compassion strives to provide healthcare to all its members that are safe, effective, patient-centered, timely, efficient and equitable.”
– From the Expert Advisory Panel of the project to Develop Hospital Standards to Advance Cultural competence. Patient and Family-Centered Care The Joint Commission