LDI Health Policy Seminar Series

The Samuel Martin III, MD
Memorial Lecture

Risa Lavizzo-Mourey, MD, MBA
Senior Vice President and Director
Health Care Group at the Robert Wood Johnson Foundation

IOM report Unequal Treatment and the major issue

April 26, 2002
2:00 - 3:30 pm

John Morgan Building, Class of 62 Auditorium
(3620 Hamilton Walk)

Summary Biosketch

On April 26, 2002, LDI welcomed back longtime Penn colleague Risa Lavizzo-Mourey, MD, MBA, to present the Samuel P. Martin III Memorial Lecture. Dr. Lavizzo-Mourey, now Senior Vice President and Director, Health Care Group of the Robert Wood Johnson Foundation, discussed key findings from the Institute of Medicine's 2002 report Unequal Treatment: Confronting Racial & Ethnic Disparities in Health Care.

Dr. Lavizzo-Mourey, co-chair of the IOM committee that developed the report, began by outlining the growing diversity in this country. "In the future there won't be minorities; there will be a constellation of people, but no majority group and no minority group." That racial and ethnic minorities have heath disparities is not new, she said, although the focus has been on unequal access to health care. The numbers of uninsured individuals without access to health care remains significant in recent immigrants as well as in minority populations of low socioeconomic status.

Instead, the IOM report focuses on the quality of care of minorities receive within the health care system--those who have at least some access. This focus enabled the IOM to separate the access issue from the disparities issue, and to examine the role of stereotyping, bias, and uncertainty in creating and maintaining health care disparities.

The committee's work involved an extensive literature review of studies in health disparities, supplemented by focus groups. The report drew on the IOM's definition of quality of care to answer the question: "Is the care being given based on the knowledge at the time and the knowledge that will produce the desired outcome?"

Dr. Lavizzo-Mourey outlined some of the findings of the study. "The primary finding, that outcomes are worse and that disparities exist, is truly compelling." The committee found significant disparities among blacks and whites in cardiovascular disease care, cancer care, renal transplantation, HIV/AIDS treatments, and asthma care. Dr. Lavizzo-Mourey described the process of reviewing the data with an anecdote about the asthma literature. When the committee reached the data on asthma, members began to realize the extent of disparities. "It looks like everything you don't want to have happen to you, is what minorities have happen to them: they have to receive their care in the emergency room, they are less likely to be seen by an asthma specialist, and are more likely to use corticosteroids and anticholinergic drugs. It was at this point that there was a groundswell behind the notion of disparities."

"The second finding was that racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequalities that continue to exists in many sectors of America," Dr. Lavizzo-Mourey said. She emphasized the need to keep in mind this broader context of racial prejudice and segregation that is America's not too distant past. She also stressed that the root cause of disparities cannot be found in one aspect of health care: patients, physicians, the system, or financing. But rather, "There is a little bit of blame to go around."

Dr. Lavizzo-Mourey commented that much of the literature on racial disparities addresses disparities between Caucasian and African-American populations, even though the issues surrounding health and health care disparities are far more general. From focus groups, the IOM found that minority groups (particularly Latinos) are more likely to feel that they are treated with disrespect than are white patients.. Focus group participants identified linguistic barriers and communication difficulties as major deterrents to receiving care for minority populations, and voiced little hope that health care for minorities would improve in the future.. The IOM weighed in on the role of bias, stereotyping, and clinical uncertainty on the part of health care providers. Dr. Lavizzo-Mourey said that the committee found little evidence of overt bias. However, she noted that "physicians use the same kind of cognitive shortcuts and stereotyping that everyone else does. So the question is a paradox: how can well-meaning, highly educated health professionals who really want to do good, who go into this to do good, do things that contribute to discrimination and disparities?" Dr. Lavizzo-Mourey illuminated this issue with a personal experience of stereotyping as she tried to get care for her child in an emergency department. Her experiences illustrated how stereotyping influences the clinical encounter. The IOM report recommends a variety of strategies to address health care disparities. First and foremost, Dr. Lavizzo-Mourey highlighted the need to raise awareness of disparities as a real issue.. Second, she pointed out that "fragmenting health care plans along socioeconomic lines seems only to exacerbate the problem. When there are plans that are primarily Medicaid or primarily commercial we see more differences." The stability of the relationship between patients and providers needs to be promoted, especially in publicly funded plans, and patients' rights should extend to both publicly funded enrollees and commercial enrollees. The IOM also urged that interpreter services be available to overcome language barriers between providers and patients. Other recommendations included a renewed emphasis on the use of evidence-based guidelines in clinical care, and payment systems that ensure adequate services and provide incentives to reduce disparities. Dr. Lavizzo-Mourey also noted policy recommendations such as the need to provide greater resources to the U.S. Department of Health and Human Services' Office of Civil Rights, (to investigate civil rights violations in health care) and the urgency of recruiting more racial and ethnic minorities to the health care professional workforce. Finally, the IOM stressed the need for more research across racial groups, and more detailed analysis of race effects versus socioeconomic effects in disparities. "Actions need to be comprehensive and sustained," she concluded. Dr. Lavizzo-Mourey stressed that the report looked at only very small piece of the disparities picture and that the larger issue continues to be one of access to care. "We are talking about what happens once you get in the door, and to me there's a much bigger problem of who is able to get in the door and we need to not lose sight of how big an issue that is."

Dr. Risa Lavizzo-Mourey is the Senior Vice President and Director, Health Care Group at the Robert Wood Johnson Foundation. Prior to coming to the Foundation, Dr. Lavizzo-Mourey was at the University of Pennsylvania where she was the Director of the Institute on Aging, Chief of the Division of Geriatric Medicine, the Sylvan Eisman Professor of Medicine, and Health Care Systems, and Associate Chief of Staff for Geriatrics and Extended Care for the Philadelphia Veterans Administration Medical Center. Dr. Lavizzo-Mourey was the Deputy Administrator of the Agency for Health Care Policy and Research now known as the Agency for Health Care Research and Quality within the Department of Health and Human Services. While in government service, Dr. Lavizzo-Mourey was a member of the White House Health Care Policy team, including the White House Task Force on Health Care Reform where she co-chaired the working group on Quality Care and consultant to the White House on issues on health policy.

Dr. Lavizzo-Mourey is a member of the Institute of Medicine of the National Academy of Science and, has served on numerous federal advisory committees including the Task Force on Aging Research, the Office of Technology Assessment Panel on Preventive Services for Medicare Beneficiaries, the Institute of Medicine's Panel on Disease and Disability Prevention Among Older Adults, and the National Committee for Vital and Health Statistics where she chaired the Subcommittee on Minority Populations. In March 1998, she completed service on the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. She is currently co-chairing a congressionally requested Institute of Medicine study on racial disparities in health care.

Dr. Lavizzo-Mourey is a Master of the American College of Physicians-American Society of Internal medicine. Her professional memberships also include the American Geriatrics Society, the Association of Academic Minority Physicians, the national Medical Association, the Association for Health Services Research, and the Gerontological Society of America.

Dr. Lavizzo-Mourey earned her medical degree at Harvard Medical School followed by a Masters in Business Administration at the University of Pennsylvania's Wharton School. After completing a residency in Internal Medicine at Brigham and Women's Hospital in Boston, Massachusetts, Dr. Lavizzo-Mourey was a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania where she also received her Geriatrics training.

The panel is sponsored by the Division of General Internal Medicine and the University of Pennsylvania Leonard Davis Institute for Health Economics

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