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Diversity Increases Quality Outcomes

© Ice Miller LLP © Ice Miller LLP

John Oliver's award winning HBO series, Last Week Tonight, recently highlighted the disparate treatment of many patients based on gender and race in its episode entitled, "Bias in Medicine." Mr. Oliver presented evidence that women are less likely than men to be treated for pain and other serious health conditions such as heart attacks and also emphasized the lack of women's participation in clinical research programs. Additionally, the episode presented disturbing study results, which indicate a significant number of medical professionals incorrectly believe certain biological distinctions exist between races that, in reality, do not exist (e.g. the thickness of skin).

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A relative lack of diversity in health care facilities and challenges faced by minority patients in the health care system has been a topic of discussion for years, but the issue appears to be gaining momentum. There are likely a variety of reasons for increased awareness of these issues; however, one catalyst for this awareness is undoubtedly the rapidly changing demographics of the United States. Projections indicate that over the next forty years non-Hispanic white Americans will no longer make up a majority of this country. Instead, Hispanic Americans will compose 28.6% of the population, 18% will be African American, and 12% will be Asian American.[1] Low birthrates combined with relatively high rates of immigration are causing a racial and cultural shift.

At the same time, the gap between the demographics of the U.S. and the makeup of the health care industry is large. In today’s health care facilities, only 4.4% of the general medicine workforce is African American and only 5.1% is Hispanic.[2] Further, a 2015 survey by the American Hospital Association’s Institute for Diversity in Healthcare Management found that while minorities represented 32% of patients in hospitals, they comprised only 14% of hospital board members, 11% of executive leadership, and 19% of mid-level and first-level managers.[3]

While health care facilities might seek to increase the diversity of their employees for the sake of equity or fairness, recent research indicates that diversity is also associated with better patient outcomes. A meta-analysis of recent studies of diversity in the healthcare industry suggests that patient-provider race concordance is associated with better patient ratings of care among adult primary care patients.”[4] Further, some studies have shown that workforce diversity is one of the many tools that can help the frequency in which patient populations engage with the health care system at the appropriate time.[5] For example, one study suggests that additional African American doctors would reduce the mortality rate due to heart disease among African American males by 19%.[6] These and other research studies indicate that the provider-patient relationship optimally includes a congruence of cultural, racial, and language attributes.

In the reverse, culturally discordant encounters appear to be a significant fact in creating the unequal and avoidable excess burden of disease borne by members of ethnic minority populations in the United States.[7] Despite an overall decrease in mortality rates among minority populations, these figures still significantly lag mortality rates in non-Hispanic white Americans. Minority patients are less likely to seek care, especially on a proactive or preventative basis, with doctors that are non-congruent with their race, culture, or language.

Of course, hospital executives are well aware that governmental payors such as Medicare are changing the way they reimburse health care providers. Instead of only paying for the number of services a health care facility provides, Medicare is also tying reimbursement to providing high quality services. For example, the Hospital Value-Based Purchasing (VBP) Program, established by the Affordable Care Act, implements a pay-for-performance approach to the payment system that accounts for the largest share of Medicare spending in numerous hospitals across the country. Under the Hospital VBP Program, Medicare adjusts a portion of payments to hospitals beginning each fiscal year based on either how well they perform on each measure compared to all hospitals, or how much they improve their own performance on each measure compared to their performance during a prior baseline period.

As governmental payors fully implement existing plans such as the VBP program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program and establish new metrics for tying reimbursement to quality outcomes, hospitals must continue to think strategically and innovatively to increase quality performance. Health care facilities will undoubtedly make changes to their internal processes to remediate some of the more obvious issues related to quality. However, the evidence suggests that, in addition to these changes, a diverse medical staff may not only be an ethically appropriate goal, but also a sound strategy for increasing quality outcomes, particularly in facilities that serve diverse populations.

Additionally, as more research becomes available that establishes increased quality outcomes as a result of diverse medical staffs; it is possible that the standard of care related to hiring practices at health care facilities may shift so diversity becomes an expectation rather than an aspirational goal. If this shift occurs at some point in the future, health care facilities that are unable to provide patient access to diverse teams of medical professionals may face an increased risk as a result of such deficiencies.

For more information on this topic, contact James Banister at james.banister@icemiller.com or (317) 236-5812. James is an attorney at Ice Miller LLP in the Health Care Group. He offers clients detailed and practical guidance on how to minimize the risk while maximizing the benefits of a diverse workforce.

Summer associate Anthony Dey contributed to this article.

This publication is intended for general information purposes only and does not and is not intended to constitute legal advice. The reader should consult with legal counsel to determine how laws or decisions discussed herein apply to the reader’s specific circumstances.
[1] Colby, Sandra L. and Jennifer M. Ortman (2015). Projections of the Size and Composition of the U.S. Population: 2014 to 2060. United States Census Bureau.
[2] Fact Sheet: The Need for Diversity in the Health Care Workforce. Health Professionals for Diversity Coalition.
[3] Diversity and Disparities: A Benchmarking Study of U.S. Hospitals in 2015 (2016). Institute for Diversity and Health Equity. http://www.diversityconnection.org.
[4] Cooper, Lisa A. and Neil R. Powe (2004). Disparities in Patient Experiences, Health Care Processes, and Outcomes: the Role of Patient-Provider Racial, Ethnic, and Language Concordance. The Commonwealth Fund.
[5] Esposito, L. (2016). Diversity in Health Care Providers Helps Patients Feel More Included. U.S. News & World Report.
[6] Alsan, Marcella, Owen Garrick, & Grant Graziani (2018). Does Diversity Matter for Health? Experimental Evidence from Oakland. NBER Working Paper Series. http://www.nber.org/papers/w24787.
[7] Kagawa-Singer, Marjorie and Shaheen Kassim-Lakha (2003). A Strategy to Reduce Cross-cultural Miscommunication and Increase the Likelihood of Improving Health Outcomes. American Medicine. Vol. 78, No. 6.

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