Digital Tools Can Begin to Help Address Structural Racism in Healthcare-The HSB Blog 3/21/22

Our Take:

The increased use and availability of digital health during COVID has begun to address some of the structural racism in healthcare improving satisfaction and broadening access to healthcare delivery. Ultimately, this may be a first step towards eliminating the patient divide and unconscious biases that currently exist. Nevertheless, structural racism in healthcare remains and has impacted the quality of care provided and the health outcomes of patients amongst diverse populations. However, exposing structurally embedded racist ideologies or unconscious bias will be a task of its own. Culturally competent care and diversity training will improve the quality and access to healthcare facilities. The use of telehealth has become an integral part of healthcare for many during this pandemic as its delivery methods cater to the needs and comfort of patients.

Key Takeaways:

A 2018 study found that Black patients had higher incidence rates of hospital-onset MRSA infection than White patients (6.21 per 100,000 vs. 2.94 per 100,000)
One study found that black patients were significantly less likely than white patients to receive analgesics for extremity fractures in the emergency room (57% vs. 74%), despite having similar self-reports of pain
A recent study in the journal Cultural Infectious Disease Reports found higher rates of infection and death during COVID-19 were seen in racial/ethnically diverse groups
Black, Hispanic, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander patients were reported to receive worse care than White patients for 35–40% of quality measures evaluated according to the 2018 National Healthcare Quality and Disparities Report

The Problem:

Recognizing how structural racism has played a significant role in the quality of care that is being provided to patients brings to light certain challenges racially diverse groups face. The hesitation of racially diverse groups in approaching healthcare providers is often associated with fear of being stereotyped. Unfortunately, unconscious bias among healthcare professionals still exists which can impact the attitude and tone that they use when speaking to patients of color. For example, there is still a high percentage of medical professionals that believe there are fundamental biological and innate differences that exist between Black patients and White patients when assessing pain or possible treatments. Century-old beliefs in physiological differences amongst racial groups when observing pain tolerance and management have only added to the structural inequities and poor health outcomes of diverse groups. For example, according to Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between Blacks and Whites, "For example, in a retrospective study entitled "Ethnicity and analgesic practice"the study found that Black patients were significantly less likely than white patients to receive analgesics for extremity fractures in the emergency room (57% vs. 74%), despite having similar self-reports of pain." Similarly, “Racial/Ethnic Inequities in Healthcare-associated Infections Under the Shadow of Structural Racism: Narrative Review and Call to Action” found that “the downstream consequences of structural racism have manifested throughout the COVID-19 pandemic, with Black, Native Americans, and Hispanic populations experiencing disproportionately higher rates of infection and death compared to White Americans.” Unfortunately, two years into this pandemic very few changes have been seen, however, the use of telemedicine has been quite helpful. Certain telehealth platforms provide patients with the option of audio, video, or audio-video calls with translators/interpreters that could be incorporated into the session if necessary.

The Backdrop:

Structural racism has played an integral part in the structuring of our healthcare systems starting from the conception of public healthcare facilities. Construction plans would include racially segregated sections that would be both unequal in standard and funding. For example, in 1946 the federal government enacted the Hospital Survey and Construction Act, commonly known as the Hill-Burton Act, to provide for the construction of public hospitals and long-term care facilities. Although the act mandated that healthcare facilities be made available to all without consideration of race, it allowed states to construct racially separate and unequal facilities. In addition, federal programs such as the Medical Assistance for the Aged program (also known as Kerr-Mills), which provided health care to the poor, “were underfunded and few states participated, especially states with large populations of Black Americans.” In addition, although these facilities were available would not be easy for many people of color to access other support services like insurance, health benefits, or paid sick leave were often not granted for workers that were not White. According to “Structural Racism in Historical and Modern US Health Care Policy”, “the National Labor Relations Act of 1935 expanded union rights for workers, which resulted in higher wages and benefits such as health insurance for those represented by unions. However, the act did not apply to the service, domestic, and agricultural industries, and it allowed unions to discriminate against racial and ethnic minority workers employed in other industries such as manufacturing.” Inconsistencies in the law such as this kept diverse groups struggling for adequate income and insurance coverage and it made healthcare inaccessible for many. In fact, it was not until the creation of Medicare and Medicaid programs in the 1960s that the first steps towards addressing the hardships of racial/ethnic minority populations were actively taken. However, the enactment of these social programs shaped an uneven, structurally racist system that did not look to provide long-term benefits to people of all colors. The federal government provided a free range of options for states to design eligibility requirements often making it difficult for diverse and minority populations to qualify for coverage. The financial strain, inadequate facilities, and limited resources made accessing care difficult and set up an unfortunate structurally racist and inequitable healthcare system.

The implementation of the Affordable Care Act during the Obama Administration continued to target the inequities within healthcare and hoped to improve the accessibility and quality of care provided. However, while there are multiple avenues through which one can acquire coverage, the level of deductibles and out-of-pocket expenses required by even the most inexpensive plans can quickly add up for those of limited financial means resulting in financial and mental strain. In addition, due to the lack of higher education access and opportunities for people of color, there is a lack of racially diverse groups in the healthcare professions. This lack of diversity has only added to the structural issues and racially strained environments where unconscious bias still clouds the judgment and treatment provided to minority populations. For example, as noted in the study “Structural Racism In Historical and Modern US Health Care Policy”, “compared with White patients, racial and ethnic minority patients are less likely to receive evidence-based cardiovascular care, kidney transplants when indicated, age-appropriate diagnostic screening for breast and colon cancer, timely treatment related to cancer and stroke, appropriate mental health treatment, and adequate treatment when presenting suffering from pain.” As a recent article in JAMA noted, “systemic racism is both pervasive and understudied in medical care”, our healthcare environment and future healthcare professionals need to understand and incorporate culturally competent practices that would eradicate structurally racist practices. Due to COVID-19 telehealth platforms have begun to bridge this divide and have helped increase positive communication and patient satisfaction. For example, telehealth had enabled scheduling flexibility, available translators/interpreters, and a broader range of appointment options (audio, visual, or audio-visual) to cater to underserved patient needs.

Implications:

The importance of combatting structural racism and inequities that exist within our healthcare system has become a primary goal to ensure equitable treatment of diverse populations going forward. The use of telehealth and digital platforms has shown positive patient satisfaction and overall health outcomes in racial and ethnic minority populations. The incorporation of cultural competence training increased diversity training in healthcare delivery, broader community assessments, as well as continued input in the form of evaluations from both patients and staff, will provide greater insight into the issues as they arise.

While telehealth provides flexibility and multiple features that could help ease patient experience, there are many individuals who are either not comfortable technologically nor technologically advanced and thus may continue to face greater difficulty. New policies that will aim to modify and lift licensing restrictions for telehealth services will also provide a broader, more diverse network of healthcare professionals for patients to consult. According to the Federation of State Medical Boards, approximately nineteen states and territories have implemented long-term interstate telemedicine waivers as of February 2022. However, despite an easing of licensing restrictions and discounts on telehealth services one concern that remains is how to overcome the issue of Internet and broadband access in communities that do not currently have it and where it may take time for them to get it. While significant funding has been dedicated to the development of broadband for such communities, that will take time. In the interim many have proposed the development of Internet hubs that offer free Wi-Fi to aid the adoption of digital health services for underserved communities. No matter how the issue of broadband access is conquered, as noted in a recent issue of JAMA Network, “only when outcomes are culturally sensitive and meaningful when minority communities are able to collaborate with research and researchers, and when studies point out not just the existence of but also the amelioration strategies for care inequities will we start to navigate our way through this most complex of ecosystems to achieve more optimal, beneficial, compassionate, culturally sensitive, and equitable …care for all.”