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Racial divide found across health plans

African-American Medicare patients fare worse than whites even when they belong to the same health plan, according to a study released today that provides new evidence of the persistent medical divide between the races.

The study, from researchers at Harvard and Brown universities, found that the gap exists even in high-quality health plans, suggesting that the issue of healthcare disparities cannot be attributed to individual, inferior doctors, the researchers said.

Instead, they said, their findings show that the problem of healthcare disparities is widespread and deeply rooted, reflecting medical, social, and economic factors ranging from physicians not being culturally sensitive, to patients not being able to afford medications or find stores offering fresh fruits and vegetables.

"If you look at this study, most health plans have a problem with disparity regardless of their own quality," said Dr. Amal N. Trivedi of Brown, lead author of the report. "This was a universal problem across the entire Medicare managed-care system."

The most striking gap identified by the study's authors was in patients who had suffered serious heart problems. The researchers found that while 72 percent of white patients with previous heart disease had their cholesterol under control, only 57 percent of blacks did. Black patients were also less likely to have their blood pressure and blood sugar well controlled, according to the study published in today's Journal of the American Medical Association .

The authors and other health policy specialists called for better research to help understand what might be causing disparities -- including how genetic differences between the races may influence response to medication.

Previous studies had looked at whether blacks and whites nationwide received medical tests at the same rate -- which they don't. Health policy specialists not involved with today's report called it a landmark study because it looked at the actual health of the patients and found disparities regardless of where they lived or whether they belonged to high- or low-quality medical plans.

The study reviewed the medical status of more than 334,000 elderly patients enrolled in 151 health plans from 2002 to 2004.

Dr. John Ayanian , another author of the study, said that it did not include Hispanics, Asians, and Native Americans because the government reports used in the research did not consistently distinguish among those groups.

Susan Pisano , spokeswoman for the trade group America's Health Insurance Plans , said that insurers, as well as physicians and hospitals, now widely acknowledge that disparities exist.

"What's different about today versus five or 10 years ago is that we're moving beyond just identifying that there is a problem to figuring out how we're going to solve it," Pisano said. "This is a complicated problem, and I don't think anybody thinks there is 'the' answer."

The elimination of the racial divide in health status has emerged as a major political and medical issue in the past two years, with Boston Mayor Thomas M. Menino last year declaring it the single most pressing health concern in the city. Earlier this year, following the lead of Boston's health agency, regulators ordered Massachusetts hospitals to start collecting detailed information on the race and ethnicity of all patients and then analyze it, looking for evidence of disparities.

Such efforts are already underway at two of the nation's most prominent hospitals, Massachusetts General and Brigham and Women's, as well as at health plans such as Harvard Pilgrim .

Dr. Joseph R. Betancourt , director of the Disparities Solutions Center at Mass. General , said doctors there now realize that "it's easy for me to check a box and say, 'I told the patient to go get a foot exam.' But where the rubber hits the road is whether I've assessed whether they have any barriers to getting it.

"I don't think that it's a matter of a doctor having a black patient in front of them and saying, 'I want to control that patient's high blood pressure less,"' Betancourt said.

When doctors are telling patients to lead healthier lives, they are now inclined to make fewer assumptions and, instead, ask more questions, he said. For instance, a physician might say to a patient: "Is your neighborhood safe for walking? Are there stores where you can buy produce?"

When executives at Harvard Pilgrim recognized that Hispanic diabetics in the plan were undergoing fewer eye exams than other patients, tests were made available last year -- without a co-payment -- at Stop & Shop grocery stores in New Bedford and Dorchester.

But only 2.5 percent of the members the plan contacted went in for screening, said Kathy Coltin , Harvard Pilgrim's director of External Quality Data Initiatives. So this year, the plan is trying a different approach by offering coupons for free eye tests at a chain of optical offices.

"One of the big struggles is we don't know what works ... to end disparities," Coltin said. "Right now what we're trying is trial and error."

When Venatia Jones was diagnosed with breast cancer at the age of 46, she said, healthcare professionals sometimes failed to take into account the realities of her life as an African-American woman who did not then have health insurance. For instance, she said, a doctor "strongly admonished" her to have a $3,000 genetic test -- but never asked whether she could afford it.

"I don't think that the system intended for me to feel separated and afraid, but that's how I felt," said Jones, now 49 and an assistant to the campus director at Springfield College's Boston campus. "If everyone could just be more humane, our health plans would be better and more tailored to us as individuals."

Stephen Smith can be reached at

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