Racial and ethnic disparities in access to health care could be a result of discrimination. In this study, the researchers wanted to identify differences in the rates at which patients, based on their race, are offered primary care appointments and how long they wait for those primary care appointments. They also wanted to understand the mechanisms by which how discrimination occurs. The researchers performed a cross-sectional study using 7 simulated black, Hispanic, and white callers. The callers requested appointments from 804 randomized primary care offices in 2 urban centers of Texas. The simulated calls were done by research assistants, who randomly assigned offices to schedule an appointment supplying the same basic information. Race and ethnicity were signaled through callers’ names and voices. The main outcomes and measures were appointment offer rates, days to appointment, and questions asked during the call. Of the 7 callers, 2 identified non-Hispanic black, 3 identified as non-Hispanic white, and 2 identified as Hispanic. Of 804 simulated calls, 299 were from white callers, 215 were from black callers, and 290 were from Hispanic callers. Overall, 582 callers were offered appointments. In unadjusted analyses, black and Hispanic callers were more likely to be offered an appointment than white callers. However, after adjusting for whether insurance status was revealed, the significance of the unadjusted analysis was lost. In adjusted analyses, black callers and Hispanic callers were 44% and 25.3% more likely, respectively, to be asked about insurance status than white callers. Black and Hispanic callers received appointments further in the future than white callers. In conclusion, black and Hispanic callers were more likely to be given an appointment, but were asked more frequently about insurance status. In addition, they experienced longer wait times than white patients, indicating a barrier to timely access to primary care.
The researchers wanted to understand differences in the rates at which racial/ethnic minority groups were offered primary care appointments, as well as the number of days they wait for primary care appointments.
People of color experience worse health outcomes than white people in the U.S. While there is much evidence for biological and environmental determinants of these health disparities, little is known about how the healthcare system plays a role. These disparities may result because of discrimination in access to timely services. Black and Hispanic patients wait longer than white patients to be seen by a physician and in the emergency department. These delays may contribute to poorer physical and mental health.
Most primary care appointments are scheduled over the phone, and phone staffers have control over appointment times they offer. Names and voices can signal race, ethnicity, and gender. Appointments scheduled over the phone likely include racial, ethnic, and gendered signals. It is possible that biases in scheduling staff result from minority groups being turned away or given later appointments. Scheduling staff may have direct hostility toward minority patients, or draw on stereotypes to make assumptions about minority patients’ insurance status.
Previous studies link racial and ethnic disparities in health to 1 of 3 determinants: self-reported discrimination, explicit bias, or implicit bias toward black and Hispanic patients by health service professionals. Explicit bias can be controlled, while implicit bias is automatic and outside of an individual’s control. Overall, research suggests that black patients report bias from healthcare professionals more frequently, healthcare professionals are more biased toward black and Hispanic patients, and that implicit bias is more common than explicit bias in healthcare professionals. While informative, these studies measure attitudes rather than behaviors. Field experiments are necessary to understand behavior, but these studies are rare in healthcare settings. A few small-scale field experiments have suggested that healthcare professionals show favoritism based on class, insurance status, race, and gender. The mechanism by which these biases occur is unclear.
In this study, the researchers investigated whether the rates at which black and Hispanic patients were offered appointments, as well as the number of days they had to wait for appointments, were different from those of white patients. They also categorized the kinds of questions that schedulers asked and analyzed differences by race and ethnicity to try and understand the mechanisms by which discrimination may occur
The researchers used the Texas Medical Board database of active licensed physicians to select offices to call. They selected physicians within the study’s geographic area and retained primary care physicians which included family medicine, family practice, general practice, general preventive medicine, gynecology, internal medicine, obstetrics and gynecology, sleep medicine, endocrinology, and preventive medicine. This provided the researchers with 1888 offices to choose from, and they selected a subset using simple random sampling.
7 female callers were recruited. Each invented a fake name that signaled their gender, racial, and ethnic identity. All grew up in the U.S. with their biological relatives and lived in communities whose racial/ethnic identities matched their own.
Script and Procedures
During each call, the caller introduced herself and asked to be scheduled for the next available appointment as a new patient. All callers used the same procedures and script to supply identical personal information. They chose to report health problems to increase plausibility that an uninsured patient would seek an appointment. The health problems were common to primary care practitioners but were not emergencies.
Callers documented information for each primary care practice using a standardized data collection form. They recorded date and time, whether the call was answered, and the number of minutes they were on hold. They noted questions/comments by the scheduler, whether an appointment was scheduled, and the date/time of the appointment.
The researchers assessed whether patients were treated differently during the call. They used a linear regression analysis that was controlled by variables for socioeconomic, healthcare market, and demographic characteristics as well as practice specialties and physician races.
Because insurance status was the most common question, the researchers also evaluated the extent to which insurance was associated with appointment offers and days to appointment.
All analysis was performed in Stata.
Differential Treatment Leading to an Offer
Out of 1081 calls, 481 calls had complete data and were included in analysis. Black and Hispanic callers were engaged differently in their discussions with practice schedulers. 444 callers were asked about insurance status, with black and Hispanic callers more likely to be asked. Questions about insurance were the most common and where disparities were the highest. Black and Hispanic callers were 44% and 25.3% respectively more likely to be asked about insurance status.
Differential Treatment in Offer and Days to Offer
Overall, 582 callers were offered appointments. In unadjusted models, black and Hispanic callers were more likely to be offered appointments than white callers. The addition of controls did not change results for offer rates. Callers who were asked about insurance status were more likely to be offered an appointment, which suggests that more appointments were offered if insurance status was revealed.
The mean time until offered appointments was 10.8 days. Black and Hispanic callers received later appointments compared with white callers. When restricting analysis to those who were asked about insurance, black callers were offered appointments 7.04 days later than white callers.
In this study, black and Hispanic callers seeking medical appointments were treated differently than white callers. Schedulers offered more appointments to black and Hispanic callers, such that there was no evidence of discrimination against minority patients in terms of accessing appointments. However, black and Hispanic patients waited longer on average for the appointment, suggesting that they face barriers to timely access to appointments. Black and Hispanic patients were also asked more about insurance status, and those asked were offered appointments at different rates. Schedulers may believe that race and ethnicity are associated with insurance status. Those who asked about insurance appeared to be inquiring in response to race and ethnicity signals, which would constitute discrimination.
The finding that disclosing uninsured status was positively associated with an appointment offer was surprising. However, schedulers distinguished patient groups by Medicaid vs. non-Medicaid status rather than insured vs. uninsured status. Texas Medicaid disproportionately covers black and Hispanic individuals. Determining whether schedulers asked minority patients about insurance status because of a higher expectation of Medicaid was beyond the scope of this study.
The study should be replicated using a nationally representative sample of primary care offices, and expand to include callers with a broader demographic range. Insurance status should also be randomized to understand its effects on being offered appointments.