Beyond Economics

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For the healthcare industry, cultural competency is the key to reach america's burgeoning minority and immigrant communities.

It seems a simple enough word, one that should have a simple meaning. But for some knowledgeable Seattle doctors and nurses, this Cambodian word evokes the complex challenges now facing the healthcare industry as it contends with a growing number of patients who are unfamiliar, even uncomfortable, with the ways of American medicine.

Cambodian refugees first began arriving in Washington State in the early 1980s, part of a worldwide wave of immigration that has added nearly a million people a year to the U.S. population in the past 20 years. Health officials soon discovered that, as with so many other newcomers, communicating with the refugees required subtle adaptations at every stage of the healthcare process. Staff at Seattle's hospitals and clinics, for example, had to learn the Cambodians' medical idiosyncrasies, including iron deficiencies in youngsters after prolonged bottle feeding with cow's milk, and high rates of Hepatitis B among older adults, a legacy from Southeast Asia. And while healthcare providers quickly learned that krun literally means "fever" in Khmer, the language of Cambodia, it took detailed interviews with 26 Cambodian patients at the Harborview Medical Center to discover that the term is used for a wide range of symptoms that generally fall under the rubric of "feeling sick." Similar expressions exist in Thai, Laotian, and Vietnamese.

Compared to less-culturally sensitive and more universal products such as automobiles or fast food, the healthcare industry faces special communications challenges in an era of mass immigration because health and medicine are intimate subjects closely linked to traditional ways and foreign languages. Latinos, for example, make up nearly two-thirds of the population eligible for the State of California's Healthy Families program, but few were applying for enrollment. To reach this population, the California Primary Care Association launched its own bilingual outreach campaign last summer, complete with public service announcements and an 800 number.

For both public and private healthcare providers, a burgeoning new market awaits, replete with disproportionately young, child-bearing, and often upwardly mobile consumers. But gaining access to that market requires a running jump across many cultural divides, at a time when delivering healthcare involves far more precise and sophisticated interchanges between patient and provider than was the case even 50 years ago.

Today those exchanges of information often involve an immigrant with a limited mastery of English and an even more modest understanding of the arcane practices of U.S. health insurance and managed care. In addition, there are millions of native-born Americans who only recently gained economic access to the full range of health services, and are still learning how to take advantage of them.

Whether the task is pre-certifying a referral to a specialist, making a diagnosis, or mass-marketing analgesics, every sector of the healthcare industry now faces potentially serious difficulties in addressing its newest beneficiaries. For the patient, it can be a life-or-death matter. For those in the business of healthcare, it could be a matter of long-term survival.

"The healthcare industry has a huge opportunity for organic growth over the next 20 years as immigrants, minorities, and others move up the economic ladder and gain access to healthcare coverage," says Alfred L. Schreiber, president of Diversity Business Imperatives, a newly formed firm providing strategic planning and recruitment services.

"But achieving that growth will require efforts to bridge gaps created by language, culture, and history, because healthcare is still very much geared to the traditional white consumer," he says.

Along with executives at many healthcare and marketing companies, Schreiber sees a mixed message in well-publicized studies showing that minorities are at least twice as likely to be uninsured as whites. It is certainly bad news that 36 percent of nonelderly Latinos go without health coverage, compared to only 14 percent of whites. But the good news is that the other 64 percent do have some kind of private insurance or Medicaid, and their numbers are growing.

Even if the proportion of the Latino population with coverage remains static, the actual number of Latinos who are paying customers will continue to increase dramatically because immigration and high birth rates are fueling a galloping population growth three times the national average. And as more and more immigrants work their way out of the informal economy and into jobs with healthcare benefits, the size of the Latino market for health products and services will increase exponentially. Similar growth - though not on the same scale - is also taking place among Asians and Pacific Islanders, who already have rates of private coverage approaching that of whites (69 percent versus 79 percent, respectively), according to "Key Facts: Race, Ethnicity & Medical Care," a report released last fall by the Kaiser Family Foundation.

Leaving aside for a minute the question of whether the glass is half full or empty, it is important to remember that the entire healthcare system pays disproportionate costs for the large number of Americans who lack coverage. People without insurance typically skip optional treatments or preventative care, see a doctor only when they have been sick for a while, and often use hospital emergency rooms as walk-in clinics. This kind of care is expensive, and the costs of caring for the uninsured are typically passed on to paying patients, adding to the overall inflation of healthcare costs.

Economic factors alone, however, do not explain racial and ethnic disparities in access to healthcare: Asthmatic black children of all incomes, for example, are hospitalized at about three times the rate of white children, according to the Kaiser report. And the response from government and industry has not centered solely, or even primarily, on trying to remedy differences in earnings. Instead, some of the boldest initiatives are aimed at differences in language and culture - more elusive factors that also help explain the disparities. As a practical matter, providers and insurers are realizing that they can take steps to make themselves more accessible and better understood for far less money than it would cost to make themselves more affordable.

"The medical system can be difficult to negotiate for native-born Americans, and so you have to imagine what it is like for someone who has never heard of an HMO before coming here from Latin America or Asia, who doesn't know generic substitutes exist, and who does not speak English," says Dr. Eric M. Alvarez, president of the Florida Pharmacy Association. "These people will Americanize themselves in good time, but in the meanwhile, there are dangers in the potential for misunderstandings."

Manufacturers of some name-brand prescription drugs like Claritin, the allergy remedy, already have conducted ad campaigns in languages other than English, and printed information on medicines and diseases is now available in some foreign languages. But, Alvarez says, "Often a printed message is not enough. You need a personal contact with someone who speaks the patient's language to ensure an understanding of all the do's and don'ts. Confusion over something as simple whether a drug should be taken on a full stomach or an empty one can have important consequences."

Some health organizations have responded aggressively to satisfy such patients' needs and get a lock on the market they represent. Concerned that it was not attracting a large enough share of the Asian population in the San Francisco area and hearing complaints about culturally insensitive treatment from the Asians who did use its services, Kaiser Permanente conducted an extensive market study, including surveys and focus groups. The HMO discovered that while Chinese immigrants represented a comparatively young, fast-growing niche for its managed-care products, cultural factors such as language posed the chief roadblocks to penetrating that market, according to Ronald Knox, vice president for diversity at the California-based healthcare giant.

"We were promoted into action by our members' expressed needs, then we recognized the importance of the changing demographics and saw an opportunity to execute an improved business plan," Knox says.

Initially, multilingual signs were put up at one of Kaiser Permanente's major San Francisco medical centers. Then a center-wide, full Chinese module, with support staff fluent in several Chinese dialects, was created to help take clients from registration to treatment to release. And eventually, Chinese-speaking physicians and technicians were hired. As it was implementing the changes over the course of five years, Kaiser Permanente almost doubled its share of the Chinese market in San Francisco.

To explore the various factors that contribute to racial and ethnic disparities in healthcare, the Morehouse Medical Treatment and Effectiveness Center examined nearly 200 separate studies dealing with the topic and completed a synthesis of the findings, included in the Kaiser Family Foundation report last fall. While socioeconomic factors explain some important disparities in access, the study concluded, "The literature shows that racial and ethnic inequalities persist in significant measure for several disease categories and service types, even after controlling for important confounding variables."

For example, several researchers examined the Veteran Affairs medical system, which treats all eligible veterans free of charge, and found substantial disparities in the treatment of cardiac and stroke patients. Even after adjusting for age, eligibility, socioeconomic status, and geographic region, one investigator found that African Americans diagnosed with a stroke were 53 percent and 72 percent less likely than whites to receive two of the most effective procedures.

Previously, findings of this sort have prompted charges of racism, and while bias presumably persists in the medical establishment to the same degree it does in the rest of society, the research also points to other and more complex explanations, including some that lie with the patients themselves. Several studies have shown that blacks and Latinos are more likely than whites to refuse certain optional invasive procedures, whether they involve surgery or are as simple as the digital rectal examination to screen for prostate problems.

But even on this point the findings are not straightforward because minorities seem to shun some kinds of procedures but not others. Most recent studies indicate that African American women, for example, are not disadvantaged compared to whites when it comes to screening procedures for breast and cervical cancer. In fact, one researcher found that after all socioeconomic differences are equalized, black women are nearly three times more likely than whites to get a Pap test. Meanwhile, Latino women lagged in almost every category, with significantly less use of screening procedures than either whites or blacks, according to the Morehouse analysis. The differences between African American men and women in their use of common cancer-screening procedures points to differences in gender roles that assign middle-aged females with special responsibility for care-taking and maintenance of self-esteem. Though confounding and controversial, these behavioral patterns are now in the spotlight because ethnic and racial disparities are increasingly an important topic in the long-running national debate over the healthcare system.

"The complex challenge facing current and future researchers is to understand the basis for such disparities, and to determine why disparities are apparent in some, but not other disease categories and service types," says the Morehouse study.

While researchers explore the interaction of the many factors that go into healthcare disparities, the federal government and some parts of the industry are pressing forward. Since 1965, federal regulations have prohibited discrimination in government programs receiving federal funds, regardless of whether the discrimination is intentional or not. Even though the causes are not fully understood, the discriminatory effects of the healthcare disparities are well documented and, under the Clinton Administration, that has been enough to kick Washington into action. And once federal regulators are involved, industry executives are much more likely to examine their own corporate behavior.

Medicare, the vast federal health insurance program for the elderly and disabled, often has helped improve the care of minorities by setting standards and threatening to withhold payment from those that fail to comply. By those means Medicare promoted the desegregation of hospitals in the 1960s and has impelled hospitals to provide services to patients with limited proficiency in English in the 1990s.

But with projected total benefit payments of more than $212 billion in 1999, Medicare faces its own crisis over racial and ethnic disparities. Minorities as a share of the elderly population will more than double over the next quarter century, rocketing from 14 percent in 1995 to 31 percent in 2025, according to the Census Bureau; this at a time when the overall size of the elderly population is doubling due to the aging of the baby boom generation. This has major implications for the question of how to ensure Medicare's long-term viability, an issue that has been the focal point of debates over federal fiscal policy through much of the last decade.

Sicker and poorer, generally speaking, elderly minorities present a greater challenge and a greater cost to the government than whites. Nearly half of black (43 percent) and Latino (48 percent) Medicare recipients are not in good health, compared to about a quarter of whites, according to the Kaiser report. Meanwhile, two-thirds of white beneficiaries currently have some form of insurance or retirement benefits to supplement Medicare, compared to only a third of black beneficiaries and a quarter of Latinos. Medicare's costs could rise disastrously and threaten the federal budget with renewed deficits if it must fund the treatment of a rapidly growing number of elderly who have received inadequate healthcare most of their lives and still lack funds for any optional or preventative treatments.

Avoiding that fate will require reducing disparities in the next decade or so before boomers, including a sizable cohort of African Americans, retire en masse, putting the Medicare system under maximum stress, and while the vast wave of immigrants who have come in the past 25 years are still working and thus capable of improving both their long-term health prospects and their access to private insurance.

The Clinton Administration recognized the importance of this demographic moment. Last year the President set a goal of eliminating ethnic and racial healthcare disparities by 2010. So far most of the effort has gone into research, with the promise that a detailed strategy for six key areas such as cardiovascular disease and childhood immunizations will be published this year. Already, the effort appears to be having some impact.

"As soon as you raise potential compliance issues, you raise corporate awareness, and so Washington has guaranteed that this issue is now on everyone's radar screens," says Knox of Kaiser Permanente.

Practitioners across the country are already learning new skills that fall under the rubric of "cultural competence." Harvard Pilgrim Health Care, among the largest managed-care systems in New England, contends that its culturally competent healthcare "welcomes both the culture of the patient and that of the clinician," borrowing strengths from both in a "dynamic engagement."

If it is put into practice, this is more than jargon.

"Old assumptions regarding the needs and the diagnoses and treatment of patients based upon a predominantly homogenous, western, white-male model must be reexamined and modified to meet the health needs of an increasingly pluralistic society, of growing numbers of people of color, women, older persons, and immigrants," said Dr. Deborah L. Gould, chief of pediatrics for Kaiser Permanente in Fremont, California, in a speech on cultural competence.

In practice, major healthcare systems like Kaiser Permanente and Harvard Pilgrim have found themselves investing not just in printed translations and live interpreters but also in retraining staff to handle encounters with people who speak little English and whose concepts of health and healing were shaped elsewhere. Now, matters like eye contact and posture have taken on new meanings as clinicians learn how gestures are interpreted in different cultures. Moreover, diversity initiatives are increasingly considered important to continued profits. At Harvard Pilgrim, for example, senior management has had to meet specific performance goals in this area for the past four years. (But, in the complex business of managed care, volume alone is no guarantee of success. Harvard Pilgrim discovered that earlier this year when it went into receivership, in part because it expanded its membership too quickly, officials said.)

"The challenge is that there is no quick fix," says George Yasutake, a medical science manager for Bristol-Myers Squibb. "Every group, really every patient, is different when it comes to the means by which they understand medical information. If you want informed choices, if you want patients who can take care of their own health, you need to spend time with people, and that may be the most difficult thing to accomplish."

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