islander, and other populations, and what that spells out in many data points, you see astor rex's and stars -- use the asterisks -- you see asterisks and stars. they're all these types of infrastructures, and we have looked at how we can start capturing some of those demographics, because what you do not measure, you do not see, so this idea of capturing a some of the data in terms of so what is it your incidence of heart disease, what is the true incidence of cancer, which is the true incidence of these diseases we have mentioned on specifics, especially the native american population, part of it is just being able to capture folks, to be able to reach folks, and actually being able to have them answered some of the did questions and then be

able to put that, after simplifying it, put that in some of the data collection systems we have, so one of the strategies we are using are very targeted, where we specifically have specific efforts to reach folks and to be able to capture the population appropriately. . >> there is a push to look at health outcomes and i believe that that would be extremely dangerous.

in order to try to find out and tease out the specific reasons why we have this wide variation in health outcomes. >> ok, first, commissioner? >> i want to thank the panel. it has been very informative. my immediate family and their spouses have eight positions. i am the only black sheep, the only one that is not a position. i am interested in all the testimony about the existence of the disparity and i would be glad to yield to hhs and its addressing of some aspects of that. our special jurisdiction is somewhat limited. that is to focus in on the

causes and the extent to which there is explicit racial discrimination. in particular, the last three that tried to get at that, as i understand, this is a terrible general -- a terrible overgeneralization. there are socio-economic reasons that have a big part to play before there is interaction. this may be related to the other factors. then there are those that impact the health care system. we have heard that there is at

least a concern with some research that has to do with the clinical experience and by s and some has to do with the and even this in the quality of care. i wonder, i think the doctor began to put some of this into words. what percentage -- pick of the disease if you know it. some diseases are caused by these factors -- what percentage of the disparity does not have really much to do with the system and then, what percentage is related within the health care delivery system to possible bias and implicit differences? what percentage, even if it is a wild guess, just to give us a

sense as to what your research suggests and the same for the doctor. >> let me try to answer that question in the context of a paper that i wrote with another of my collaborators. we published it. here is what we found. if you're interested in black- and-white differences in 30 and 90 day survival after a heart attack, what we found was that when you look at the role of provider quality, the role of provider quality explained about 60% of the variation. there is still 40% that you could actually also say that it was the fact that within a particular hospital, blacks and whites were treated by different

groups. maybe they varied in quality. we were not able to control it down completely. there is an enormous wall of the care system that you were treated at. that becomes more important when you narrow the window over which you are looking at outcome differences. if you change the outcome measured to what is the measure of geography in explaining 30 day mortality, then that explains that 100%. the hospital is going to be very important for the first week. once your discharged from the hospital, then a bunch of other factors -- one short discharged from the hospital, then a bunch of other factors come -- once you are discharged from hospital, then a bunch of other factors come into play.

we have, essentially, no preventative measures. in the paper, i alluded to this. if it were published, i could talk more about it. we look at the delivery of preventive services and we were able to assess that, on average, about half of the services look at the socio-economic status. blacks were going to doctors that treated more than provided lower quality care. then there was the residual that had to do with other issues.

these were due to different treatments of black and white patients by the same doctor, things that we would argue are statistic anomalies. we are not seeing any evidence that this is within the doctor's office. it is all around the doctor's office. >> i think you very much. i think the panel for a final presentation. i have two small questions. the first one comes from research that has been done in the asian-american community. as you know, there are a lot of different perceptions of the asian american community. most of them tend to be in a u- shaped curve. this goes to new immigrant

populations as well. to what extent does linguistic and cultural competency and access have on access for those who need it. i throw the open to the panel. >> i will take a first stab at that. as i mentioned earlier, it has a definite if not significant enough not tremendous impact on some of the civil factors that we have today. we alluded to a concordance between providers. i think that, implicit with that, is the ability to provide that care. i think that if a patient understands what you are talking about, but that you understand the patient. it is particularly important. the it is harder to capture in

some of the other outcomes that others have spoken about, but that is what is implicit in that 40%. those are the other parts of data were you see these intrinsic and implicit factors. i want to also allude to that other point that you pointed out. when you look at the data, use the specific and significant health disparities -- uc pacific -- you see specific insignificant health disparities. -- you see significant -- you see specific and in the -- you'll see a specific and significant health disparities. it is difficult to suppress for

it. i happen to serve on the board of a public hospital in atlanta. we have a tremendous problem because we have a growing hispanic population and the very issue that dr. gramm mentioned is one that we're dealing with. we do not have enough interpreters to speak to the spanish population that we are serving. we have been told by leaders in the hispanic community that many of their citizens to not come to the hospital. that is a factor that weighs on the care that the individual receives. in 1996, in the new england the journal of medicine, there was a study with the university of california san francisco and it showed that black or hispanic physicians were three times more likely to establish their practices in black or hispanic

areas. the health care in their communities improved. one might say that this is not due to bias in the system, but i think that depends on how you define that. i think -- i do not refute the fact that when one looks very closely at a lot of kattegat's, you may not find differences if you look very finely, but there are gross discrepancies in the health-care system that have an impact on people's lives. i think it is important that, as we are working to improve the health of americans, that we do not dispose of those factors that have a system that makes it difficult for a growing sector of a population to receive the care that they need. one of the challenges that we face as a society is a growing

health burden as well as problems in our educational system. if they are not addressed, over time, that will erode the strength of our country. i think we have to look as broadly as we need to, but not dismiss those systemic problems that appear with the ability of people to receive care on the basis of them come, education and bias. i happen to be old enough to have grown up in the south, where my family drove 41 miles to see a black physician rather than go in a room that said black patients verses white patients. i find that as bias. my parents defined that as baez and they would not accept that. i think that we have to be careful not to try and dismiss

the factors in a system that do impair the ability of our patients to receive the care that they need. >> mr. chair, my second question was actually more along those lines. i wanted to get his reaction. i do not tend to think that there is, at the micro level, an individual discrimination. but the fact that there is disparity and that it exists and that it is documented and it seems to be consistent over time, whether it is with native american healthcare or asian american or latino or african-

american, there is still something amiss. not so much whether someone wants to stick it to this report that group, but nevertheless, it comes under resources. were people decide to put their resources. -- where people decide to put their resources. i am just wondering, from your point of view, why do we still keep coming up with the fact

that there is this 60% that we cannot explain or a tribute to this. at that as the real core of what this hearing is about because hopefully we are past the time when secretary sullivan does not want to go into a room that says whites-only and blacks only. there is still something wrong. i think we recognize it. the question is, what is it? especially in this health care debate that is going on. how will that change impact what we are currently struggling with right now? >> i think you made a good point. one of the things that i would hate for us to walk away from this meeting with is that somehow the health care industry is somehow bypassed towards taking care of patients. it is not. i think that the overwhelming number of health-care providers

try to provide the best possible care to all their patients. i have had the opportunity of working in six different geographic reasons -- geographic regions. having said that, we have to understand that we all come into this profession with our own life experiences. decisionmaking is based a little bit of that life experience that we have to make judgments. some of those judgments are based on our ability to figure out how patients will be able to carry out certain treatment plants for will be able to understand certain treatment plants. some of those decisions that are made are made of those types of mindsets i would say that one of the things that you have to be

concerned about -- types of mindsets. i would say that one of the things that you have to be concerned about is that when you add language into that, it creates even more complexities. having an interpreter does not solve the issue. one of the things that was found out was that family members were serving as interpreters and many times, the patients don't want to tell their family members what is going on. you have phone calls or you have to make a decision. even those were not found to be adequate. i think that speaks to a couple of issues. one has to do with work force diversity and this is one of the most important aspects. the second faint has to deal with poverty. it just by being poor, you are likely to live six-nine years less than if you are not poor.

then, as a uniform answer, i think we need to look at literacy as a bigger picture. many of our patients come to our offices and our facilities without the best literacy understanding, especially when you talk about a medical problem. when you talk about the complexity of the health-care industry and you put the resources into all those other areas that impact the care of the individual rather than on that patient, we have to utilize the entire service. >> i think the doctor was or to say something. " i think the answer to your question is that we really do not know what makes up a lot of that noise. that is why i mentioned that at that fine grain level, you really do need prospective studies and almost a

sociological focus. that may sound a touchy-feely, but there are some methods to standardize these encounters and follow them. as far as what is referred to as a cultural competency, i think that the position is clearly an important figure. when it comes to chronic illness and patients that have this lifelong burden of diet and exercise and when you are poor in your life is chaotic, that is not always a priority. to have a relationship with the personnel and the nurses and the secretaries, they are the ones the patients have the best relationship with. those are the folks that are drawn from the community. they are the ones that follow what and they are the ones that engage them. that engagement is really huge. that is where i would focus.

that is a local level kind of thing. >> i think the statistics show that even more. >> i agree. >> i guess i wanted to focus on the call " -- the competence area. on the other hand, there is a bit of attention and that. you think that if cultural competence is the root of the problem, the studies would have come out differently. it sounds like when minorities are going to the same medical facilities, you would expect, since they but specialize in non minority patients, that they would be the least culturally competent. yet, what i am understanding is

that it is in an area where we would expect greater cultural confidence. regardless of who those doctors are, they are getting repeat patience and you would expect that afterward. he would think it would become more culturally competent. is there some way that this can be pursued in your studies to figure out just how important the cultural confidence issue is? >> it strikes me as a significant tension between what is being discussed and what we are getting as an outcome. if that is not the problem, what is? >> my response to that is that i do not think of the world being either mechanism later be. when it comes to things like treating heart attacks and strokes, it seems to be the quality of the hospital.

that is one to determine survival all lot more. if you look at the quality of ambulatory diabetes care, you see differences within the networks. that might speak to a number of stories about education and literacy and the potential benefit that a patient perceives but it also speak to cultural competency. the culture of cultural competency is not going to yield the same kind of benefit as the focus of raising the quality of ambulatory care. often, we will get a lot of benefit from focusing on that, but it is swamped by the fact that it looks like a minority patients are going to providers that are having real trouble of delivering high-quality care. >> the right way to clarify this is that there are a variety

of issues that play and that we have to not try and find a unilateral force there were bullet solution, but if you look at the data, cultural confidence is very important. if you look at the full spectrum, you will find that as particularly important as well. you will understand there are quality of care issues. if it was a linear situation, the doctor pointed out that it would be about 60-40. you do see where the number is part of a number of factors. that is truly what we're trying to get. i think that some of the work that the doctor and peter have published has been instrumental in understanding the role of geography. it the full spectrum of they

also deals with cultural competency. >> i might add, one of the major problems in health care is compliance by patients with instructions from the provider. they have a tremendous problem with a lack of compliance. many patients may not be following their physician's orders. that is often based on not understanding what the provider has said or not trusting the provider. that is where cultural confidence in terms of the ability to understand the patient and the patient's values affects the health outcome. >> a couple of things. the doctor can jump in if he disagrees. a specialist focus on nuances. they do that to emphasize that

we see the large problem, even as we drove down and eliminate possible explanations. no one is sitting here saying that there are not large differences that are intolerable and unconscionable. what we are focused on is your question as to what is the most to teach it clean up active approach for eliminating those within our constraints. on to the topic of cultural confidence, you are absolutely right. given that there is no difference in the treatment of blacks and whites, he is the doctor is well matched to both patient groups or this cultural overlay is done correlated. on the topic of cultural confidence, i have questions and can't stearns. the first is there is a general

complacency between health literacy and linguistic competence. i view those as somewhat different issues. the issue of those challenges are real and well documented. dr. sullivan mentioned a profound one. those issues are often inflated. i think that it currently lacks is sufficiently robust definition an order for people like the doctor and i to study it. i think it is uncertain, given the lack of definition, how we address cultural competency shortfalls if one exists. i am not sure that in reaching the work force with minorities and members of other ethnic groups, which is something that i support, is something that would address this gap.

i am a physician and educator. i do think that it is important to appreciate that medical schools are moving towards a cultural competence specialist in their group. the work of the dr and minal work -- and my work have found gaps in clinical knowledge among some doctors and other features taking them away from that environment. we have to appreciate that every layer of the man that we put on them to enrich their ability in one area necessarily takes away from some other area. we have to be very careful that we do not take away the doctor's ability to read and e k g in an instant in order to teach him to talk to a patient that is dealing with a myocardial infarction.

>> i have one question for the doctor. you mentioned that geographical disparities. do you have any research that tells us what the disparities are between the rural versus suburban verses urban residents? >> that work speaks more towards the of enormous body of work that has come out of the program. what you see there is a strong association from northern new england states, along with other states like montana. then there is a gradient that is moving down. for the purpose of this analysis, california looks like a southern state. its