ISSUES IN DERMATOLOGIC HEALTH CARE DELIVERY IN MINORITY POPULATIONS

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ISSUES IN DERMATOLOGIC HEALTH CARE DELIVERY IN MINORITY POPULATIONS Amy J. McMichael, MD, and Sharon Jackson, PhD

It is well known that African Americans are at low risk for one of the most serious diagnoses in dermatology-skin cancer. A consequence of this lower cancer risk has been an undervaluing of the importance of appropriate dermatologic care in this population. In fact, there are many other skin diseases and disorders that not only cause significant morbidity among African Americans, but also emotional and psychological sequelae. Understanding the factors that influence use of health care services and care-seeking behaviors among African Americans requires acknowledgment of the considerable heterogeneity that exists in this population and the potential discordance in beliefs, values, and culture that may exist between the care provider and the care recipient. Issues of importance to care recipients or patients influence care-seeking and health maintenance behaviors, whereas those more relevant to care providers have a major influence on the timely provision of the appropriate level of care. This article examines barriers and challenges to providing dermatologic care among African Americans and provides recommendations

and suggestions for improving care delivery to this population.

PATIENT-RELATED BARRIERS

African Americans are a heterogeneous group. Consequently, there is considerable intraracial variability in the relative importance of factors that affect access to care, services use, and care-seeking behaviors among African Americans. One such factor is the availability of financial resources to purchase needed services. Although lack of financial resources is an important barrier for any population regardless of race, the greater prevalence of poverty, low income, and lack of insurance among African Americans places them at greater risk for inadequate care. Friedman et all2 found that African Americans were more likely than whites or Hispanic Americans to report cost as a barrier to seeking follow-up dermatologic care. In this study, cost was reported as a barrier more frequently than time constraints, fear of cancer diagnosis, or fear of treatment. In addition to inadequate care, populations lacking ade-

From the Departments of Dermatology (AJM) and Public Health Sciences (SJ), Wake Forest University School of Medicine, Winston-Salem, North Carolina ~~

DERMATOLOGIC CLINICS VOLUME 18 * NUMBER 2 * APRIL 2000

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quate insurance coverage are not screened despite documented need.27 Other factors with a potential negative impact on use of dermatologic services by African Americans include use of folk medicine or home cures; fear of a cancer or other serious diagnosis; and lack of knowledge about skin cancer, including recognition of symptoms. In a study of alternative medicine use, approximately 7% of those who reported having skin problems also reported use of alternative therapy for the condition within the past 12 month^.^ African Americans were less likely than other racial groups to report use of the alternative therapies examined. It is not clear, however, whether this difference was due to racial differences in reporting of alternative therapies, interpretation of the phrase alternative therapy, or failure to include therapies more culturally relevant and common to African Americans. It has been suggested that fear of finding cancer and fatalism (i.e., inevitability of death associated with a specific condition or disease) hinders the participation of some African Americans in screening programs and subsequent necessary treatment. Although research in this area is limited, the small body of empiric evidence suggests that African Americans may be more likely than whites to express fatalistic views and beliefs19 and to have fear of a cancer diagnosis, which may act as a barrier to seeking follow-up medical care for suspicious skin lesions.12 The role that knowledge and education play in influencing health behavior is well established. Adequate knowledge and accurate information help individuals navigate the health care system and recognize and process accurately signs and symptoms of illness or disease. Decisions regarding participation in screening programs also require adequate knowledge and information. There is little empiric evidence regarding symptom recognition and knowledge of skin cancer or other skin disorders among African Americans. Evidence from the general oncologic literature suggests that many African Americans lack basic information about the incidence, risk factors, symptoms, and screening strategies for cancers. This lack of information causes

significant morbidity and mortality among 23 5, sf 13, African Ameri~ans.~, Care-seeking behaviors are also influenced by beliefs about perceived personal risk and attitudes regarding prevention and treatment efficacy. Available literature suggests that African Americans are equally as likely as whites to practice skin self-examination even though they perceive a lower risk for skin cancer.12,25 They are less confident, however, of their ability to perform the examination correctly or detect something unusual and are less likely to schedule a follow-up appointment immediately if a suspicious skin lesion is found.12,25 It is conceivable that individuals with such attitudes and behaviors might delay or postpone initial contacts with the medical system. Potential patient-related barriers to use of dermatologic services by African Americans have been suggested by existing literature. Given the relatively small samples of African Americans included in studies to date, however, caution should be exercised when interpreting and generalizing these findings to the larger population.

PROVIDER-RELATED BARRIERS

Characteristics of the health care delivery system often act as barriers to dermatologic care for African Americans. For African Americans with less flexibility in work schedules or for whom time off (even for medical purposes) results in lost wages, simple logistical concerns, including available appointment times or clinic hours, not only limit accessibility, but also may affect income and livelihood. Although such concerns are not specific to African Americans, the effect may be more pronounced because of the greater prevalence of manual labor or unskilled job positions in this population. Medicine in the United States operates primarily as a fee-for-service enterprise, generally with a time-of-service requirement for payment from the care recipient or a thirdparty payer (either private or government sponsored). Access to care is especially tenuous for lower-income and elderly African Americans who rely on the governmentsponsored Medicaid and Medicare programs.

ISSUES IN DERMATOLOGIC HEALTH CARE DELIVERY IN MINORITY POPULATIONS

Dermatologic services, often considered elective services, can be especially difficult to access because of cost or limited reimbursement by health insurance carriers. Of concern is the fact that only 50% (on average) of poor African Americans are covered by Medicaid.6 Many providers do not accept Medicaid, possibly because of the lower reimbursement schedule. Consequently, almost half of all Medicaid beneficiaries are treated in only 10% of all private primary care physicians’ offices,6 further limiting access. A growing body of literature suggests that there are racial differences in access to certain medical treatments and procedureslO,l4 and quality of care.14 Racial differences were evident even in a system of open access to medical care for eligible patients in which physicians were salaried (two hallmarks of the managed care system) and after adjustment for disease severity, comorbid conditions, demographic characteristics, and source of care.18,26 Many studies have reported that African Americans, the elderly, and those who are poor are less likely to receive expensive diagnostic tests.7 It is unclear what impact health care reform in the form of managed care may have on these racial inequities in access to care. In the managed care system, primary care physicians serve as gatekeepers, regulating (and perhaps also rationing) access to care. Many African Americans express concern that the managed care system, with its proposed spending cuts, will exacerbate the racial discrepancy in access, leading to further reductions in access to care for the African American c~mrnunity.~ Several studies are particularly interesting within the context of managed care. Researchers have shown that a reduction in the number of visits to dermatologists has accompanied the growth in managed care and health maintenance organization and prepaid insurance providers,’l suggesting a decrease in referrals to dermatologists or an increase in dermatologic care by primary care physicians. Solomon et alZ4reported that, as compared with dermatologists, family practice physicians were significantly deficient in their ability to recognize common and serious dermatoses. In a study by Owens et al,17 only one

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third of patients who received care from a primary care physician before the dermatologist were satisfied with the previous physician’s care. In this study, 87% of all patients described direct access to dermatology as being important to their health care. Taken together, these studies have important implications for the appropriate provision of dermatologic care. For African Americans, in whom diagnosis is more challenging because of skin complexion and potential differences in symptom presentation,16the issues of misdiagnosis, reduction in specialty referrals, and delayed referrals to dermatologists may be particularly problematic. Inadequate communication between physicians and patients and misconceptions or stereotypic attitudes on the part of the care provider may contribute to underuse of health care services.I5 An example of underuse from misconceptions or stereotypic attitudes would be the primary care physician who does not refer a patient for dermatologic consultation because the physician assumes the patient cannot take an additional day off work to see the specialist. SUMMARY AND FUTURE DIRECTIONS

Empiric evidence regarding access to and use of dermatologic care services is scant. There is strong evidence, however, to support the existence of racial disparities in health care access in the United States, and there is no indication that this pattern differs for the specialty of dermatology. Although the combination of factors that contribute to this disparity are not well understood, existing literature suggests that barriers to use of dermatologic services by African Americans include a number of factors related to the patient, provider, and health care delivery system. To increase access to dermatologic care for African Americans, multiple strategies are needed. From the patient’s perspective, these include research into the sociocultural, psychological, and behavioral barriers to dermatologic care in population-based studies; examination of the influence of alternative or

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folk medicine and home remedies on careseeking behaviors; and development of culturally relevant health education messages that provide accurate information on the risk of skin cancer and other serious dermatologic conditions, including risk factors and preventive measures. The reduction or elimination of financial barriers to health care through, for example, creative programs that expand eligibility for Medicaid and other state plans should improve access to care. Using what is known regarding the role of family and cultural beliefs in seeking health care would help health care professionals deliver care to this population? Future interventions should also address strategies to increase nondermatologist physician knowledge of dermatologic disease in African Americans, remove barriers to direct access to dermatologic care, eliminate racial differences in the use of medical treatments and procedures, and monitor closely the trend in racial differences in health status within the current managed care environment. Health care providers should be educated to avoid overgeneralizations, because no population is homogeneous. Specific strategies to improve health care should also include training on intraracial diversity?2This strategy has been successful in other health specialties and could improve delivery of dermatologic care. Racial differences in access to care have been attributed to racism within the health care system and on the part of care providers: Cultural sensitivity education and training for health care providers are essential for the identification and elimination of mvths and personal prejudices that iduence iccess to and quality of care for African Americans and other minority populations. Because the bulk of health care occurs in the outpatient setting, health care institutions and professionals that implement innovative outreach to African American communities can improve access to dermatologic care.2o Programs designed to increase education and screening in African Americans are few, but several have been effective." Similar programs geared to educating African American patients on dermatologic Kealth may improve knowledge and decrease fear of disease. The American Medical Association (AMA) has es-

tablished a Minority Affairs Consortium, which has as one of its missions to address minority health disparities.l This consortium is just the beginning of efforts to develop new AMA policy on training minority physicians, training all physicians to be cognizant of racial inequities, and improving cultural competence among physicians. Specific programs for dermatology could occur through collaborations with African American physicians and other physicians whose patient populations include large percentages of African Americans, public health departments, community organizations that provide health education to African American communities, and social organizations with outreach to African American communities. All of the factors identified as potential barriers to dermatologic care among African Americans can be overcome. It requires a multifaceted, comprehensive approach to health care, however, that not only requires input from health care providers, but also sociologists, psychologists, social workers, behavioral scientists, and care recipients themselves. The solutions require multilevel strategies directed toward individual, community, and societal issues. Given the projected growth in the African American population over the next few years, it will become increasingly important to identify ways to deliver appropriate dermatologic care efficiently.

References 1. American Medical Association: Report of the Board of Trustees, Committee C. Report 15 Submitted to AMA House of Delegates Meeting, Chicago, IL, June 1999 2. Bagley sp, Angel R, Dilworth-Anderson P, et al: Adaptive health behaviors among ethnic minorities. Health Psycho1 14632-640, 1995 3. Barber KR, Shaw R, Folts M, et al: Differences between African American and Caucasian men participating in a community-based prostate cancer screening program. J Community Health 23:441451, 1998 4. Bhopal R: Spectre of racism in health and health care: Lessions from history and the United States. BMJ 316:1970-1973, 1998 5. Collins M Increasing prostate cancer awareness in African American men. Oncol Nurs Forum 24:9195, 1997 6 . Davis K, Lillie-Blanton M, Lyons B, et al: Health care for black Americans: The public sector role. Milbank Q 65:213-247, 1987

ISSUES IN DERMATOLOGIC HEALTH CARE DELIVERY IN MINORITY POPULATIONS 7. Dawson G: For African Americans: Real health-care reform or business as usual? J Natl Med Assoc 86:893-895, 1994 8. Demark-Wahnefried W, Strigo T, Catoe K, et al: Knowledge, beliefs, and prior screening behavior among blacks and whites reporting for prostate cancer screening. Urology 46:34&351, 1995 9. Eisenberg DM, Davis RB, Ettner SL, et al: Trends in alternative medicine use in the United States, 19901997 Results of a follow-up national survey. JAMA 280:1569-1575, 1998 10. Escarce JJ, Epstein KF, Coby DC, et al: Racial differences in the elderly’s use of medical procedures and diagnostic tests. Am J Public Health 83:948-954, 1993 11. Feldman SR, Williford PM, Fleischer AB: Lower utilization of dermatologists in managed care. J Invest Dermatol 10786M64, 1996 12. Friedman LC, Bruce S, Weinberg AD, et al: Early detection of skin cancer: Racial/ ethnic differences in behaviors and attitudes. J Cancer Educ 9:105-110, 1994 13. Hughes C, Gomez-Caminero A, Benkendorf J, et al: Ethnic differences in knowledge and attitudes about BRCAl testing in women at increased risk. Patient Education and Counseling 32:5142, 1997 14. Kahn KL, Pearson ML, Harrison ER, et al: Health care for black and poor hospitalized Medicare patients. JAMA 271:1169-1174, 1994 15. Lieberman LS, Stoller EP, Burg MA: Women’s health care: Cross-culture encounters within the medical system. J Fla Med Assoc 84364-373, 1997 16. McMichael AJ: Diagnosis and treatment of cutaneous disorders in African American patients. Curr Probl Dermatol 100:93-126, 1998 17. Owens SA, Maeyens E, Weary PE: Patients’ opinion regarding direct access to dermatologic specialty care. J Am Acad Dermatol36:250-256, 1997

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18. Peterson ED, Wright SM, Doley J, et al: Racial variations in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. JAMA 271:1175-1180, 1994 19. Powe BD: Cancer fatalism among African Americans: A review of the literature. Nurs Outlook 44:18-21, 1996 20. Robinson KD, Kimmel EA, Yasko JM: Reaching out to the African American community through innovative strategies. Oncol Nurs Forum 22:1383-1391, 1995 21. Scroggins TG Jr, Bartley TK: Enhancing cancer control: Assessing cancer knowledge, attitudes, and beliefs in disadvantaged communities. J La State Med SOC51~202-208, 1999 22. Shakoor-Abdullah B, Kotchen JM, Walker WE, et al: Incorporating socio-economic and risk factor diversity into the development of an African American community blood pressure control program. Ethn Dis 7175-183, 1997 23. Smith GE, DeHaven MJ, Grundig JP, et al: AfricanAmerican males and prostate cancer: Assessing knowledge levels in the community. J Nat Med Assoc 89:387-391, 1997 24. Solomon BA, Collins R, Silverberg NB, et al: Quality of care: Issue or oversight in health care reform? J Am Acad Dermatol 34:601-617, 1996 25. Webb JA, Friedman LC, Bruce SB, et al: Demographic, psychosocial, and objective risk factors related to perceived risk of skin cancer. J Cancer Educ 11:174-1 77, 1996 26. Whittle J, Congliardo J, Good CB, et al: Racial differences in the use of invasive cardiovascular procedures in the department of Veterans Affairs Medical System. N Engl J Med 329:1169-1174, 1993 27. Woolhandler S, Himmelstein DU: Reverse targeting of preventive care due to lack of health insurance. JAMA 259~2872-2874,1988

Address reprint requests to Amy J. McMichael, MD Department of Dermatology Wake Forest University School of Medicine Medical Center Boulevard Winston-Salem, NC 27157-1071