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May 17, 1995, Vol 273, No. 19 >
ARTICLE | May 17, 1995

Physician Race and Care of Minority and Medically Indigent Patients FREE

Ernest Moy, MD, MPH; Barbara A. Bartman, MD, MPH
[+] Author Affiliations

Dr Moy was a Robert Wood Johnson Faculty Fellow in Health Care Finance when this study was conducted.

Reprint requests to Box 151, 22 S Greene St, Baltimore, MD 21201 (Dr Moy).


JAMA. 1995;273(19):1515-1520. doi:10.1001/jama.1995.03520430051038
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References

Objective.  —To examine the relationship between physician race and care of racial minority and ethnic minority patients and medically indigent patients.

Design.  —Secondary analysis of data from the 1987 National Medical Expenditure Survey, a cross-sectional survey of Americans designed to provide national estimates of health care utilization and expenditures.

Setting.  —A sample representative of the total civilian noninstitutionalized US population with oversampling of minorities and the medically indigent.

Patients.  —Survey respondents aged 18 years or older who identified a specific physician as their usual source of care (n=15081, corresponding to a national population estimate of 116 million Americans).

Main Outcome Measure.  —Identification of a nonwhite physician as usual source of care.

Results.  —Of adult Americans who identified a usual-source-of-care physician, 14.4% identified a nonwhite physician as that source of care. Minority patients were more than four times more likely to receive care from nonwhite physicians than were non-Hispanic white patients. Low-income, Medicaid, and uninsured patients were also more likely to receive care from nonwhite physicians. Individuals who receive care from nonwhite physicians were more likely to report worse health, visit an emergency department, and be hospitalized. Individuals who receive care from nonwhite physicians reported more acute complaints, chronic conditions, functional limitations, and psychological symptoms as well as longer visits.

Conclusions.  —Nonwhite physicians are more likely to care for minority, medically indigent, and sicker patients. Caring for less affluent and sicker patients may financially penalize nonwhite physicians and make them particularly vulnerable to capitation arrangements.(JAMA. 1995;273:1515-1520)

REFERENCES

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Kahn KL, Pearson ML, Harrison ER, et al.  Health care for black and poor hospitalized Medicare patients. JAMA . 1994;;271:1169-1174.
2 +
Peterson ED, Wright SM, Daley J, Thibault GE.  Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. JAMA . 1994;;271: 1175-1180.
3 +
Padgett DK, Patrick C, Burns BJ, Schlesinger HJ.  Ethnicity and the use of outpatient mental health services in a national insured population. Am J Public Health . 1994;;84:222-226.
4 +
Gaston RS, Akyres I, Dooley LG, Diethelm AG.  Racial equity in renal transplantation: the disparate impact of HLA-based allocation. JAMA . 1993;; 270:1352-1356.
5 +
Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM.  Racial differences in the use of revascularization procedures after coronary angiography. JAMA . 1993;;269:2642-2646.
6 +
Whittle J, Congliaro J, Good CB, Lofgren RP.  Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med . 1993;;329: 621-627.
7 +
Johnson PA, Lee TH, Cook F, Rouan GW, Goldman L.  Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med . 1993;;118:593-601.
8 +
Todd KH, Samaroo N, Hoffman JR.  Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA . 1993;;269:1537-1539.
9 +
Escarce JJ, Epstein KR, Colby DC, Schwartz JS.  Racial differences in the elderly's use of medical procedures and diagnostic tests. Am J Public Health . 1993;;83:948-954.
10 +
Moy E, Hogan C.  Access to needed follow-up services: variations among different Medicare populations. Arch Intern Med . 1993;;153:1815-1823.
11 +
Baker DW, Stevens CD, Brook RH.  Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA . 1994;;271:1909-1912.
12 +
Stuart ME, Steinwachs DM.  Patient-mix differences among ambulatory providers and their effects on utilization and payments for Maryland Medicaid users. Med Care . 1993;;31:1119-1137.
13 +
Physician Payment Review Commission. Monitoring Access of Medicare Beneficiaries . Washington, DC: Physician Payment Review Commission; 1993;.
14 +
Weissman JS, Stern R, Fielding SL, Epstein AM.  Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;; 114:325-331.
15 +
Cooper RS, Simmons B, Castaner A, et al.  Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol . 1986;; 57:208-211.
16 +
Becker LB, Han BH, Meyer PM, et al.  Racial differences in the incidence of cardiac arrest and subsequent survival. N Engl J Med . 1993;;329:600-606.
17 +
Physician Payment Review Commission. Monitoring Access to Medicare Beneficiaries . Washington, DC: Physician Payment Review Commission; 1992;.
18 +
Rocheleau B.  Black physicians and ambulatory care. Public Health Rep . 1978;;93:278-282.
19 +
Lloyd SM, Johnson DG, Mann M.  Survey of graduates of a traditionally black college of medicine. J Med Educ . 1978;;53:640-650.
20 +
Johnson DG, Lloyd SM, Miller RL.  A second survey of graduates of a traditionally black college of medicine. Acad Med . 1989;;54:87-94.
21 +
Keith SN, Bell RM, Williams AP.  Affirmative action in medical education and its effect on Howard and Meharry: a study of the class of 1975. J Natl Med Assoc . 1988;;80:153-158.
22 +
Keith SN, Bell RM, Swanson AG, Williams AP.  Effects of affirmative action in medical schools: a study of the class of 1975. N Engl J Med . 1985;;313: 1519-1525.
23 +
Cohen AB, Cantor JC, Barker DC, Hughes RG.  Young physicians and the future of the medical profession. Health Aff (Millwood) . 1990;;9( (4) ):138-148.
24 +
Edwards WS, Berlin M. Questionnaires and Data Collection Methods for the Household Survey and the Survey of American Indians and Alaska Natives . Rockville, Md: US Public Health Service; 1989;. DHHS publication PHS 89-3450.
25 +
Cohen S, DiGaetano R, Waksberg J. Sample Design of the 1987 Household Survey . Rockville, Md: US Public Health Service; 1991;. AHCPR publication 91-0037.
26 +
Cunningham P, Altman B.  The use of ambulatory health care services by American Indians with disabilities. Med Care . 1993;;31:600-616.
27 +
Cornelius LJ.  Barriers to medical care for white, black, and Hispanic American children. J Natl Med Assoc . 1993;;85:281-288.
28 +
Cornelius LJ.  Ethnic minorities and access to medical care: where do they stand? J Assoc Acad Minor Physicians . 1993;;4:16-25.
29 +
Broussard BA, Johnson A, Himes JH, et al.  Prevalence of obesity in American Indians and Alaska Natives. Am J Clin Nutr . 1991;;53( (suppl 6) ):1535S-1542S.
30 +
Stoddard JJ, St. Peter RF, Newacheck PW.  Health insurance status and ambulatory care for children. N Engl J Med . 1994;;330:1421-1425.
31 +
Hahn B.  Health care utilization: the effect of extending insurance to adults on Medicaid or uninsured. Med Care . 1994;;32:227-239.
32 +
Franks P, Clancy CM, Gold MR, Nutting PA.  Health insurance and subjective health status: data from the 1987 National Medical Expenditure Survey. Am J Public Health . 1993;;83:1295-1299.
33 +
Cohen JW.  Medicaid physician fees and use of physician and hospital services. Inquiry . 1993;;30: 281-292.
34 +
Short PF, Lefkowitz DC.  Encouraging preventive services for low-income children: the effect of expanding Medicaid. Med Care . 1992;;30:766-780.
35 +
Cornelius LJ.  Health habits of school-age children. J Health Care Poor Underserved . 1991;;2:374-395.
36 +
Agency for Health Care Policy and Research. Health Status Questionnaires and Access to Care Supplement Data File Documentation . Rockville, Md: Agency for Health Care Policy and Research; 1991;.
37 +
Stewart AL, Hays RD, Ware JE.  The MOS Short-Form General Health Survey: reliability and validity in a patient population. Med Care . 1988;; 26:724-735.
38 +
Berwick DM, Murphy JM, Goldman PA, Ware JE, Barsky AJ, Weinstein MC.  Performance of a five-item mental health screening test. Med Care . 1991;;29:169-176.
39 +
Research Triangle Institute. SUDAAN: Survey Data Analysis Software . Version 6.34. Research Triangle Park, NC: Research Triangle Institute; 1993;.
40 +
Kochanek KD, Maurer JD, Rosenberg HM.  Why did black life expectancy decline from 1984 through 1989 in the United States? Am J Public Health . 1994;;84:938-944.
41 +
Institute of Medicine. Access to Health Care in America . Washington, DC: National Academy Press; 1993;.
42 +
Nickens HW, Ready TP, Petersdorf RG.  Project 3000 by 2000: racial and ethnic diversity in U.S. medical schools. N Engl J Med . 1994;;331:472-476.
43 +
Physician Payment Review Commission. Annual Report to Congress 1994 . Washington, DC: Physician Payment Review Commission; 1994;.
44 +
New York City Health Access Research Group. Loss of Primary Care: Health Outcomes for the Uninsured and Underinsured . New York, NY: United Hospital Fund; 1993;.
45 +
Hadley J, Cantor JC, Willke RJ, Feder J, Cohen AB.  Young physicians most and least likely to have second thoughts about a career in medicine. Acad Med . 1992;;67:180-190.
46 +
Byrd WM, Clayton LA, Kinchen K, et al.  African-American physicians' views on health reform: results of a survey. J Natl Med Assoc . 1994;;86:191-199.
47 +
LaVeist TA.  Beyond dummy variables and sample selection: what health services researchers ought to know about race as a variable. Health Serv Res . 1994;;29:1-16.
48 +
Harlow SD, Linet MS.  Agreement between questionnaire data and medical records: the evidence for accuracy of recall. Am J Epidemiol . 1989;; 129:233-248.
49 +
Quam L, Ellis LBM, Venus P, Clouse J, Taylor CG, Leatherman S.  Using claims data for epidemiologic research: the concordance of claims-based criteria with the medical record and patient survey for identifying a hypertensive population. Med Care . 1993;;131:498-507.
50 +
Bureau of the Census. Occupational Characteristics, 1970 Census of Population . Washington, DC: US Government Printing Office; 1973;.
51 +
Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures VI . Washington, DC: Association of American Medical Colleges; 1991;.
52 +
Manson A.  Language concordance as a determinant of patient compliance and emergency room use in patients with asthma. Med Care . 1988;;26: 1119-1128.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Kahn KL, Pearson ML, Harrison ER, et al.  Health care for black and poor hospitalized Medicare patients. JAMA . 1994;;271:1169-1174.
2 +
Peterson ED, Wright SM, Daley J, Thibault GE.  Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. JAMA . 1994;;271: 1175-1180.
3 +
Padgett DK, Patrick C, Burns BJ, Schlesinger HJ.  Ethnicity and the use of outpatient mental health services in a national insured population. Am J Public Health . 1994;;84:222-226.
4 +
Gaston RS, Akyres I, Dooley LG, Diethelm AG.  Racial equity in renal transplantation: the disparate impact of HLA-based allocation. JAMA . 1993;; 270:1352-1356.
5 +
Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM.  Racial differences in the use of revascularization procedures after coronary angiography. JAMA . 1993;;269:2642-2646.
6 +
Whittle J, Congliaro J, Good CB, Lofgren RP.  Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med . 1993;;329: 621-627.
7 +
Johnson PA, Lee TH, Cook F, Rouan GW, Goldman L.  Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med . 1993;;118:593-601.
8 +
Todd KH, Samaroo N, Hoffman JR.  Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA . 1993;;269:1537-1539.
9 +
Escarce JJ, Epstein KR, Colby DC, Schwartz JS.  Racial differences in the elderly's use of medical procedures and diagnostic tests. Am J Public Health . 1993;;83:948-954.
10 +
Moy E, Hogan C.  Access to needed follow-up services: variations among different Medicare populations. Arch Intern Med . 1993;;153:1815-1823.
11 +
Baker DW, Stevens CD, Brook RH.  Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA . 1994;;271:1909-1912.
12 +
Stuart ME, Steinwachs DM.  Patient-mix differences among ambulatory providers and their effects on utilization and payments for Maryland Medicaid users. Med Care . 1993;;31:1119-1137.
13 +
Physician Payment Review Commission. Monitoring Access of Medicare Beneficiaries . Washington, DC: Physician Payment Review Commission; 1993;.
14 +
Weissman JS, Stern R, Fielding SL, Epstein AM.  Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;; 114:325-331.
15 +
Cooper RS, Simmons B, Castaner A, et al.  Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol . 1986;; 57:208-211.
16 +
Becker LB, Han BH, Meyer PM, et al.  Racial differences in the incidence of cardiac arrest and subsequent survival. N Engl J Med . 1993;;329:600-606.
17 +
Physician Payment Review Commission. Monitoring Access to Medicare Beneficiaries . Washington, DC: Physician Payment Review Commission; 1992;.
18 +
Rocheleau B.  Black physicians and ambulatory care. Public Health Rep . 1978;;93:278-282.
19 +
Lloyd SM, Johnson DG, Mann M.  Survey of graduates of a traditionally black college of medicine. J Med Educ . 1978;;53:640-650.
20 +
Johnson DG, Lloyd SM, Miller RL.  A second survey of graduates of a traditionally black college of medicine. Acad Med . 1989;;54:87-94.
21 +
Keith SN, Bell RM, Williams AP.  Affirmative action in medical education and its effect on Howard and Meharry: a study of the class of 1975. J Natl Med Assoc . 1988;;80:153-158.
22 +
Keith SN, Bell RM, Swanson AG, Williams AP.  Effects of affirmative action in medical schools: a study of the class of 1975. N Engl J Med . 1985;;313: 1519-1525.
23 +
Cohen AB, Cantor JC, Barker DC, Hughes RG.  Young physicians and the future of the medical profession. Health Aff (Millwood) . 1990;;9( (4) ):138-148.
24 +
Edwards WS, Berlin M. Questionnaires and Data Collection Methods for the Household Survey and the Survey of American Indians and Alaska Natives . Rockville, Md: US Public Health Service; 1989;. DHHS publication PHS 89-3450.
25 +
Cohen S, DiGaetano R, Waksberg J. Sample Design of the 1987 Household Survey . Rockville, Md: US Public Health Service; 1991;. AHCPR publication 91-0037.
26 +
Cunningham P, Altman B.  The use of ambulatory health care services by American Indians with disabilities. Med Care . 1993;;31:600-616.
27 +
Cornelius LJ.  Barriers to medical care for white, black, and Hispanic American children. J Natl Med Assoc . 1993;;85:281-288.
28 +
Cornelius LJ.  Ethnic minorities and access to medical care: where do they stand? J Assoc Acad Minor Physicians . 1993;;4:16-25.
29 +
Broussard BA, Johnson A, Himes JH, et al.  Prevalence of obesity in American Indians and Alaska Natives. Am J Clin Nutr . 1991;;53( (suppl 6) ):1535S-1542S.
30 +
Stoddard JJ, St. Peter RF, Newacheck PW.  Health insurance status and ambulatory care for children. N Engl J Med . 1994;;330:1421-1425.
31 +
Hahn B.  Health care utilization: the effect of extending insurance to adults on Medicaid or uninsured. Med Care . 1994;;32:227-239.
32 +
Franks P, Clancy CM, Gold MR, Nutting PA.  Health insurance and subjective health status: data from the 1987 National Medical Expenditure Survey. Am J Public Health . 1993;;83:1295-1299.
33 +
Cohen JW.  Medicaid physician fees and use of physician and hospital services. Inquiry . 1993;;30: 281-292.
34 +
Short PF, Lefkowitz DC.  Encouraging preventive services for low-income children: the effect of expanding Medicaid. Med Care . 1992;;30:766-780.
35 +
Cornelius LJ.  Health habits of school-age children. J Health Care Poor Underserved . 1991;;2:374-395.
36 +
Agency for Health Care Policy and Research. Health Status Questionnaires and Access to Care Supplement Data File Documentation . Rockville, Md: Agency for Health Care Policy and Research; 1991;.
37 +
Stewart AL, Hays RD, Ware JE.  The MOS Short-Form General Health Survey: reliability and validity in a patient population. Med Care . 1988;; 26:724-735.
38 +
Berwick DM, Murphy JM, Goldman PA, Ware JE, Barsky AJ, Weinstein MC.  Performance of a five-item mental health screening test. Med Care . 1991;;29:169-176.
39 +
Research Triangle Institute. SUDAAN: Survey Data Analysis Software . Version 6.34. Research Triangle Park, NC: Research Triangle Institute; 1993;.
40 +
Kochanek KD, Maurer JD, Rosenberg HM.  Why did black life expectancy decline from 1984 through 1989 in the United States? Am J Public Health . 1994;;84:938-944.
41 +
Institute of Medicine. Access to Health Care in America . Washington, DC: National Academy Press; 1993;.
42 +
Nickens HW, Ready TP, Petersdorf RG.  Project 3000 by 2000: racial and ethnic diversity in U.S. medical schools. N Engl J Med . 1994;;331:472-476.
43 +
Physician Payment Review Commission. Annual Report to Congress 1994 . Washington, DC: Physician Payment Review Commission; 1994;.
44 +
New York City Health Access Research Group. Loss of Primary Care: Health Outcomes for the Uninsured and Underinsured . New York, NY: United Hospital Fund; 1993;.
45 +
Hadley J, Cantor JC, Willke RJ, Feder J, Cohen AB.  Young physicians most and least likely to have second thoughts about a career in medicine. Acad Med . 1992;;67:180-190.
46 +
Byrd WM, Clayton LA, Kinchen K, et al.  African-American physicians' views on health reform: results of a survey. J Natl Med Assoc . 1994;;86:191-199.
47 +
LaVeist TA.  Beyond dummy variables and sample selection: what health services researchers ought to know about race as a variable. Health Serv Res . 1994;;29:1-16.
48 +
Harlow SD, Linet MS.  Agreement between questionnaire data and medical records: the evidence for accuracy of recall. Am J Epidemiol . 1989;; 129:233-248.
49 +
Quam L, Ellis LBM, Venus P, Clouse J, Taylor CG, Leatherman S.  Using claims data for epidemiologic research: the concordance of claims-based criteria with the medical record and patient survey for identifying a hypertensive population. Med Care . 1993;;131:498-507.
50 +
Bureau of the Census. Occupational Characteristics, 1970 Census of Population . Washington, DC: US Government Printing Office; 1973;.
51 +
Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures VI . Washington, DC: Association of American Medical Colleges; 1991;.
52 +
Manson A.  Language concordance as a determinant of patient compliance and emergency room use in patients with asthma. Med Care . 1988;;26: 1119-1128.

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