Disparities in Patient Experience Underscore Implicit Bias in Health

Populations of color continue to have a poorer patient experience than their White counterparts, with the latest reporting in Health Affairs highlighting patient experience disparities within and between Medicaid managed care plans.

These findings emphasize the lasting impact on racism in the United States, as well as the continued role implicit bias plays in the medical industry.

Previous studies have found high patient satisfaction with medical care among Medicaid managed care beneficiaries, but some key disparities have emerged. Racial minority enrollees have specifically reported a worse patient experience than their White counterparts. Those disparities have largely been driven by racial discrimination and its lasting impacts on the nation.

“Well-documented and longstanding racial and ethnic disparities in patient experience are the product of interwoven patient-, provider-, and plan-level factors, as well as systemic inequality,” explained the researchers, who hail from Brown University and the University of Vermont Health Network. “Structural racism, which refers to the ways in which racial discrimination is infused into policies and social norms through mutually reinforcing systems (for example, health care and housing), is a driver of worse experiences of care for minority populations.”

For example, the deep history of racism in America may have resulted in implicit bias, which can taint patient-provider interactions. Interpersonal patient-provider relationships, different expectations for care, limited culturally responsive care, and limited patient-provider concordance—the byproduct of low diversity in the medical workforce—may all impact patient experience for populations of color.

But in order to make improvements, the researchers said they need to learn more about how patients in different Medicaid managed care plans report satisfaction. Disparities within the same Medicaid plan would indicate different patient experiences between White people and enrollees of color. But disparities across different Medicaid plans would indicate that racial minorities are disproportionately enrolled in low-quality plans.

Those two phenomena might inform different policy interventions, the researchers indicated.

The research team conducted an investigation using five years’ worth of NCQA data for just over 242,000 non-elderly Medicaid managed care plan enrollees. They particularly zeroed in on four domains of patient experience:

• whether an enrollee answered that it was “always or usually” easy to get needed care
• that they had a personal doctor
• that they were “always or usually” able to get a checkup or routine care as soon as they needed to
• that they were “always or usually” able to see a specialist as soon as they needed to

Overall, the researchers found that racial and ethnic minority enrollees reported significantly rose patient experience across all four domains. This trend was mostly driven by disparities in patient experience among people within the same plan.

Patient experience disparities were present, but negligible, across different Medicaid plans.

Among Black people, for example, patient experience disparities ranged from 1.5 to 4.5 percentage-point differences with White respondents. Those figures shook out to 1.6 and 3.9 percentage-point differences for Hispanic respondents, 9 and 17.4 percentage-point differences for Asian/Native Hawaiian/Pacific Islander respondents.

The biggest patient experience disparities varied across racial group. For example, among Asian/Native Hawaiian/Pacific Islander patients, the biggest patient experience differences happened in timely access to specialty care. There was a 17 percentage-point difference in satisfaction with this domain compared to White respondents, the researchers said.

Comparing Black and White respondents, the biggest disparity was in the “access to a personal doctor” domain, while for Hispanic patients the biggest difference was related to timely access to a check-up or routine care.

If nothing else, these figures demonstrate the nuances in health equity work and underscore the importance of racial data collection and stratifying patient experience data by race.

“Beyond data collection, states and plans should consider stratifying patient experience measures by race and ethnicity, adopting health equity performance measures, and using data from these measures to develop interventions that address racial and ethnic disparities,” the researchers said.

That level of data collection could help Medicaid managed care plans develop better provider networks and focused interventions like community-based care and patient navigation. Plans may also engage providers within their networks to build out cultural responsiveness and other efforts for racial and linguistic diversity.

But using a wider lens, the researchers emphasized the role that racism in America has played in creating differences in patient experience. Dismantling that racism will require a multi-sector effort that zooms in on the social determinants of health that disproportionately affect people of color.

“Mitigating racial and ethnic disparities will require efforts from the health care system and cross-sectoral policy reforms that address underlying social inequities and increase financial security and economic opportunity (such as by expanding eligibility and access to other social safety-net programs),” the researchers concluded.