Race and Discretion in American Medicine

The author’s focus in this article is on racial disparities in medical care provision--that is, on differences in the services that clinically similar patients receive when they present to the health care system. Racial disparities in health status, which is not greatly influenced (on a population-wide basis) by medical care, are beyond his scope here. Disparities in medical care access-potential patients\u27 ability, financial and otherwise, to gain entry to the health care system in the first place, are also outside his focus. The author begins this article by putting the problem of racial disparities in medical care provision within the larger context of disparities in health status and medical care access. In Part I, the author concedes: (1) that medical care is almost certainly less important as a determinant of health than are social and environmental influences, and (2) that inequalities in Americans\u27 ability to gain entry to the health care system probably play a larger role in medical treatment disparities than do racial differences in the care provided to people who succeed in gaining entry. He then briefly examines the moral politics behind the appearance of racial disparity in health care provision on the national policy agenda, ahead of disparities in health status and medical care access. In Part II, the author considers the links between clinical discretion and racial disparities in health care provision. He argues that pervasive uncertainty and disagreement, about both the efficacy of most medical interventions and the valuation of favorable and disappointing clinical outcomes, leave ample room for discretionary judgments that produce racial disparities. Neither existing institutional and legal tools, nor prevailing ethical norms, impose tight constraints on this discretion. As a result, provider (and patient) presuppositions, attitudes, and fears that engender racial disparities have wide space in which to operate. In Part III, the author refines this argument, pointing to a variety of extant organizational, financial, and legal arrangements that interact perniciously with psychological and social factors to potentiate racial disparities. Part IV considers the impact of the managed care revolution, contending that its cost containment strategies both contribute to racial differences in health care provision and creates opportunities for reducing some of these disparities. Part V closes with some recommendations as to how health care institutions and the law might respond pragmatically to racial disparities even as they pursue other important policy goals

Healthcare disparities and models for change.

With Healthy People 2010 making the goal of eliminating health disparities a national priority, policymakers, researchers, medical centers, managed care organizations (MCOs), and advocacy organizations have been called on to move beyond the historic documentation of health disparities and proceed with an agenda to translate policy recommendations into practice. Working models that have successfully reduced health disparities in managed care settings were presented at the National Managed Health Care Congress Inaugural Forum on Reducing Racial and Ethnic Disparities in Health Care on March 10-11, 2003, in Washington, DC. These models are being used by federal, state, and municipal governments, as well as private, commercial, and Medicaid MCOs. Successful models and programs at all levels reduce health disparities by forming partnerships based on common goals to provide care, to educate, and to rebuild healthcare systems. Municipal models work in collaboration with state and federal agencies to integrate patient care with technology. Several basic elements of MCOs help to reduce disparities through emphasis on preventive care, community and member health education, case management and disease management tracking, centralized data collection, and use of sophisticated technology to analyze data and coordinate services. At the community level, there are leveraged funds from the Health Resources and Services Administration's Bureau of Primary Health Care. Well-designed models provide seamless monitoring of patient care and outcomes by integrating human and information system resources