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Editorial Columns How Does Race Matter Anyway In two articles published since 2001 Balsa and McGuire 2001 2003 have used the language and tools of economic theory to examine several phenomena that can influence doctors decision making during clinical encounters that patients and result in racial disparities in health care These articles which adapted and extended earlier theoretical developments in labor economics were published in an economics journal and are unlikely to have been read by many health services researchers Therefore a brief summary of the articles is in order Balsa and McGuire 2003 identified prejudice clinical uncertainty and stereotyping as distinct mechanisms that can operate within the clinical encounter and lead to racial disparities in care Drawing on the literature in social psychology they defined prejudice as the holding of a negative attitude or affect against members of another racial group e g white physicians may be prejudiced against black patients By modeling prejudice as a psychological cost experienced by white physicians when they treat black patients Balsa and McGuire showed that prejudiced white physicians would provide less care to blacks than to whites Balsa and McGuire 2003 also considered the effects of two types of clinical uncertainty In the first type physicians were assumed to have only noisy indicators of patients clinical condition perhaps as a result of imperfect diagnostic tests so they were necessarily uncertain about patients precise diagnosis or severity The investigators found that under such circumstances physicians would be forced to rely on prior probabilities e g the prevalence of disease in making diagnostic and treatment decisions Thus for instance if the prevalence of disease were lower in blacks than in whites even unprejudiced physicians would be less likely to recommend treatment to black patients than to white patients As a result more black patients than white patients who would benefit from treatment would remain untreated In the second type of uncertainty Balsa and McGuire 2003 assumed that physicians have no trouble assessing the diagnosis and severity of patients in their own racial group but the indicators of patients clinical condition are noisy for patients from a different racial group possibly due to miscommunication and misunderstanding resulting from cultural or language differences They showed that even unprejudiced physicians would be forced to rely on 1 2 HSR Health Services Research 40 1 February 2005 prior probabilities to a greater degree when treating black patients than white patients Thus diagnoses and treatment recommendations of white physicians would be less well matched to individuals needs for black patients than for whites Balsa and McGuire also pointed out that because the recommended care would on average be less beneficial for blacks than for whites blacks could rationally react by going to the physician less often or complying less with treatment Balsa and McGuire 2001 2003 referred to the racially contingent diagnostic and treatment decisions that can arise from either type of uncertainty as statistical discrimination Balsa and McGuire 2003 also considered the role of stereotypes Following contemporary social psychology they defined stereotyping as the process by which people use social categories e g race or gender in acquiring processing and recalling information about others Dovidio 1999 They emphasized that stereotypes are a cognitive mechanism for simplifying and organizing social information in a complex world that they tend to be negative and exaggerated Ashmore and Del Boca 1981 and that they are not necessarily accompanied by a negative affect Drawing on models of stereotyping in labor economics they showed that certain negative stereotypes e g blacks are less likely to comply with treatment can result in less care for blacks especially if the stereotypes are self fulfilling Finally in a brief analysis of policy implications Balsa and McGuire 2003 observed that corrective actions for disparities must derive from an understanding of the underlying mechanisms Specifically efforts to improve information and reduce noise in the clinical encounter would reduce disparities that arise from clinical uncertainty However disparities that arise from prejudice and stereotypes are likely to be harder to deal with Efforts to combat prejudice and eliminate stereotypes could help and rule based policies regarding criteria for treatment and treatment rates in different racial groups could be effective in some cases In this issue of Health Services Research Balsa McGuire and Meredith 2005 attempt to conduct empirical tests of the role of statistical discrimination in health care Using data from the Medical Outcomes Study Tarlov et al 1989 the investigators assess the factors that influence white doctors decisions to diagnose black and white patients with hypertension diabetes or depression after an ambulatory visit For each disease they estimate a This work was supported in part by Grant No P01 HS10770 from the Agency for Healthcare and Research and Quality How Does Race Matter Anyway 3 traditional disparities regression in which they model a doctor s decision to diagnose a patient as a function of patient and physician characteristics as well as a signal emitted by the patient For hypertension a positive signal is the patient s affirmative response to a previsit question asking whether he has ever been told he has hypertension For diabetes a positive signal is the patient s affirmative response to an analogous previsit question or his report that he takes insulin For depression a positive signal is constructed from the responses to a previsit mental health screener and symptom questionnaire The investigators then compare the results of the traditional disparities regression and a statistical discrimination regression in which they add disease prevalence to identify physicians use of prior probabilities and an interaction between black race and a positive signal to identify communication problems between white doctors and black patients to the model s explanatory variables Balsa McGuire and Meredith 2005 find that sex age and a positive signal are significantly associated with the doctor s diagnosis in the traditional disparities regressions for hypertension and diabetes race is not significant However age and sex are not significant in the statistical discrimination regressions whereas

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