MECHANISMS CONTRIBUTING TO DISPARITIES
Mechanisms behind disparities in health and mental health care show some differences. A broad distinction, introduced by the IOM, is between disparities due to discriminatory behavior of providers (that is, treating otherwise similar patients differently according to race/ethnicity) and disparities due to access, insurance, and other factors associated with the operation of the health care system.
30
PROVIDERS’ BIAS AND STEREOTYPING.
Discrimination by providers is often the first potential source of disparities that comes to mind. Discrimination by race/ethnicity is a complex behavior that can stem from a number of sources, some malevolent, some not.
31 A provider harboring a bias against a certain group may exert less effort on behalf of a member of that group, leading to discrimination.
32 Discrimination can also stem from the negative stereotypes a provider might hold. For example, if a doctor believes that “blacks are less likely than whites to comply with treatment,” the doctor might prescribe differently based on race for otherwise similar patients. Many white Americans harbor negative stereotypes about blacks.
33 Michelle van Ryn and Jane Burke argue that “physicians may be especially vulnerable to the use of stereotypes in forming impressions of patients since time pressure, brief encounters, and the need to manage very complex tasks are common characteristics of their work.”
34
PROVIDERS’ “STATISTICAL DISCRIMINATION.”
It is also important to recognize, however, that the behavior of discrimination can result from application of clinical decision rules that in themselves seem to be neutral and even “efficient” but have different effects by race. Clinicians make decisions about what test to run or treatments to recommend in the face of considerable uncertainty about the underlying “true” condition of the patient, and their decision rules reflect that reality. The same symptom report—chest pain, for instance—may be logically interpreted as meaning different things for a young woman than for an older man. The doctor may “discriminate” by recommending that the young woman try an over-the-counter gastrointestinal medication and that the older man get an electrocardiogram (EKG). This kind of discrimination, stemming from the doctor’s rational response to uncertainty, is termed “statistical” discrimination.
35 Statistical discrimination shares with stereotyping the feature that actions are based on beliefs about group characteristics but are distinct, at least in principle, because the stereotypical belief is negative and exaggerated, whereas the clinical generalization is based on fact.
The concept of statistical discrimination is a potential link between features of disparities in mental health care as compared to other health care. The prevalence of mental disorders is generally lower among minorities, so that a clinician’s statistical “prior” that a patient is ill when encountering a minority patient should be that this patient is less likely to be ill in comparison to an otherwise similar white patient. If so, a more serious indication of symptoms would be necessary to cause a clinician to revise the prior enough to justify recommending treatment. In health, where minorities may on average be worse off than whites, application of population priors will tend to favor rates of treatment for minorities. Furthermore, in addition to a prior probability, the clinical decision-making literature refers to the “signal,” or symptom report, coming from the patient. If communication is generally worse when the patient and doctor come from different ethnic, racial, or language groups, the resultant “noisier” signal will be rationally given less weight by the doctor.
36 Minorities will be worse off on two counts, then, in connection with statistical discrimination. Their lower priors and noisier signals lead to lower probability of treatment for a patient with a given level of health care need. If statistical discrimination of this kind feeds into treatment decisions, disparities arising within the clinical encounter are more important in mental health than in general health. In the case of mental disorders, where population prevalence is generally lower for minorities and where communication/understanding may be worse, this type of provider discrimination leads to lower rates of treatment for minorities.
PROVIDER AND GEOGRAPHIC DIFFERENCES.
In the health care area, the second set of factors, provider- or geographic-level differences, are major sources of disparities.
37 Provider A may provide low-quality care to all patients, and Provider B, high-quality care to all patients, and if minorities are more likely to be seen by Provider A, these across-provider differences will account for some disparities. Geographic-level factors can work similarly, to the extent that minorities are more likely than whites to live in areas characterized by low-quality care.
HEALTH INSURANCE DIFFERENCES.
As in general health care, mental health care disparities associated with access in general, and lack of insurance, are significant in minority communities.
38 Inadequate access in poor, rural communities may be shared by everyone living there, but since minorities are more likely to live in poor communities, this form of access problem can contribute to mental health disparities.
www.vice.com
www.nature.com
