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Disparities found in health care for blacks

Many black people in the United States get their primary health care in a separate and apparently inferior system, according to a study published today -- a situation similar to the segregated neighborhood schools prevalent in some parts of the country.

The dual system for blacks and whites is not the result of doctors' bias but rather geographic segregation, the authors say, and may help explain the higher rates of disease and death that persist among blacks.

''When black patients go to the doctor, they're more likely to be treated by a doctor who can't harness the full capabilities of the health care system," said Dr. Peter B. Bach, an epidemiologist at Memorial Sloan-Kettering Cancer Center in New York who was the lead author of the study in the New England Journal of Medicine.

Examining patterns of office visits by black and white patients on Medicare, the government health insurance program for the elderly, the study found that most blacks were treated by a subset of doctors who had less training than doctors who treated whites, and who told interviewers that they were frequently unable to provide high-quality care.

These doctors, of all races, were less likely than doctors who mostly treated white patients to have passed exams showing mastery of a primary care specialty. They were more likely to report that they could not always help their patients get treatment from specialists, diagnostic imaging such as MRIs, or admission to the hospital when it wasn't an emergency. These differences remained even after the researchers took into account patients' insurance status.

The doctors' training and problems with referrals were similar to those of other doctors in their neighborhood, the researchers found, suggesting the problem was the result of geographic patterns rather than racial discrimination by doctors.

''It's not that the blacks couldn't go to other doctors," Bach said. ''These doctors practice in the neighborhoods where blacks live."

For example, a patient living in Mattapan might choose to see a neighborhood doctor who was not affiliated with any of the world-renowned Boston teaching hospitals, and that doctor could have trouble getting patients appointments with specialists, said Dr. JudyAnn Bigby, director of community health programs for Brigham and Women's Hospital. ''That's likely to result in disparities in things like cardiac interventions or hip and knee replacements," said Bigby, who was not involved in the study but is doing research on racial disparities nationally.

Numerous studies have documented that blacks are more likely than whites to die of cancer and heart disease, more likely to get diabetes and asthma, and less likely to get preventive care and screening. In Massachusetts, blacks are 17 percent more likely to die of cancer than whites and nearly three times as likely to have diabetes. The federal government has set a goal of eliminating racial disparities in health care by 2010.

But researchers are still trying to determine what is behind the differences. Other studies have shown that access to health insurance is a factor, and some have found that doctors consciously or subconsciously discriminate against black patients.

Christine Ferguson, commissioner of public health in Massachusetts, said racial disparities in health are a top priority. She said she believes that ''you can't just move people into different health practices and expect to get better outcomes," because lack of insurance and low reimbursement by government insurance programs are also involved.

''We need to figure out a way to help physicians make the connections with specialists and labs," she said. ''We have to look at training and reimbursement."

She said her department is considering whether to require health agencies that contract with the state to demonstrate improvements in outcomes for blacks and other minorities.

A physician practicing in Mattapan said the study didn't ring true. Dr. Jean Nazaire, a pediatrician for 29 years, said 95 percent of his patients are black and he has no trouble securing specialty care for them because of affiliations with three Boston hospitals. ''Most of the black physicians I know are board-certified," he said -- meaning they have demonstrated skill in their specialty by passing a test. Nazaire said he believed the racial disparities in health were due more to patients' lack of insurance and their own ''negligence" in maintaining their health.

Bigby also cautioned about concluding that board certification is a good measure of a physician's ability. She said blacks score worse on the exams than whites, as they do on most standardized testing, and that test bias rather than skill may be involved.

However, she and others said the study reinforces what earlier studies have suggested.

For example, a study of primary care doctors in New York City found that those who treated minorities were less knowledgeable about prevention and less likely to be certified in specialty areas than those who treated whites. And a study of cardiac care found that doctors who performed cardiac surgery on blacks were less qualified than those doing surgery on whites.

The new study analyzed more than 150,000 primary care visits by black and white patients over age 65 who had Medicare coverage. In addition, researchers questioned the 4,355 doctors seen by those patients in 60 cities, including Boston, about how often they could arrange specialty care for patients.

Bach said they focused on primary care because it is the gateway to the medical system for most patients. They believe the findings are applicable to patients of other ages because few of the doctors restricted their practice to seniors. But Bach cautioned that the study did not look at what care the patients actually received.

The researchers found that 22 percent of the doctors nationally accounted for 80 percent of the visits by black patients and only 22 percent of visits by white patients. These doctors, most of whom were white, provided more free care, treated more patients insured by the government's Medicaid insurance program for those with low incomes, and were more likely to practice in low-income neighborhoods, the study found. Seventy-seven percent of them had board certification in their primary care specialty, compared with 86 percent of doctors who mainly treated white patients.

Black patients seemed to seek out black doctors, seeing them 22 percent of the time, while whites saw black doctors less than 1 percent of the time. Nationwide, 5 percent of physicians are black.

Nearly 28 percent of physicians primarily treating blacks said they could not provide access to high-quality care for all their patients, compared with only 19 percent of doctors primarily treating whites.

''This paper supports the notion of institutional racism," said Bigby. ''The health care system is set up in such a way that some patients have less access to services." 

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