Unbiased Analysis of Today's Healthcare Issues

Doctors, Patients, and the Racial Mortality Gap

Written By: Jason Shafrin - Feb• 28•08

Differences in the health outcomes between white and minority patients has been well documented in the medical and economics literature. Reasons for this difference could be:

  • Unequal access to treatment. Minorities are poorer and less likely to be covered by insurance than whites.
  • Unequal treatment – Minorities are less likely to have a regular doc, which leads to discontinuities in care.
  • Unequal quality of care available to minorities – For instance, doctors who treat blacks are less likely to be board certified.

A recent paper by Emilia Simeonova tries to dig deeper into what is causing the racial mortality gap for chronic heart failure (CHF). CHF is one of the leading causes of death for the elderly and one of the major components of the racial mortality gap.


Ms. Simeonova uses a six-year panel data set from Veterans Affairs [i.e.: the VHA Medical SAS inpatient and outpatient datasets,the Beneficiary Identification Records Locator Subsystem (BIRLS) death files, the VHA Enrollment files, and the Veterans Service Support Administration (VSSA) clinic performance measures database]. The data allow the author to compare treatment within facilities rather than just between them. This is important because it is possible that blacks go to bad doctors and whites go to good doctors and this may constitute the entire mortality gap. By comparing outcomes within a clinic or within the same doctor, the author can better analyze what is causing the mortality differences.

The author calculates 3 year survival probabilities conditional on surviving two years. This should help to eliminate different CHF severity levels. In her regression, Simeonova uses patient and clinic characteristics, as well as clinic fixed effects, and time and cohort dummies. Simeonova measures doctor quality as the probability the doctor prescribes beta blockers and ACE inhibitors to patients with chronic heart failure (CHF). However, another aspect of the quality of medical care is patient compliance. Patient compliance is calculated as the number of prescriptions filled on time divided by the total number of prescriptions filled.


Simeonova finds that doctor quality accounts for 5% of the CHF mortality gap and socio-economic factors account for 20% of the differences in CHF mortality. However, the vast majority of the mortality differences are due to the fact that blacks are less likely to take their medication than whites.

I show that doctor quality significantly influences patient outcomes. While minority patients visit slightly less competent doctors, this does not explain the large gap in survival. Individual doctors are found to treat their patients similarly regardless of race. On the patient side, I demonstrate that variation in compliance triggers a racial mortality gap. Differences in patient response to treatment significantly alter survival probabilities. Considerable reductions in medical costs could be achieved by convincing patients of the importance of strictly following the therapy regimen. I estimate that targeting compliance patterns could reduce the black-white mortality gap by at least two-thirds.

Also interesting is that the paper found that when blacks have a regular doctor, they end up seeing a lower quality doctor. Nevertheless, compliance rates and mortality decrease for blacks when they have a regular doctor despite the fact that this doctor may be of a somewhat lower quality.

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No Comments

  1. Ian Furst says:

    how did she control for there ability to pay for the meds? Is it a matter of compliance or ability to pay? http://www.waittimes.blogspot.com

  2. Jason Shafrin says:

    The author does include an income variable, which should be a fairly good measure of the patient’s ability to pay. It is not perfect of course. A single man making $20,000 may be able to pay for treatment while a household with 2 adults and 4 kids with a total income of $20,000 may have less ability to pay. I do not believe that the author controlled for family size (income per person in the household) so if blacks have bigger families than whites, this could affect the ability to pay.

    Using the income variable, however, should do a fairly good job of controlling for monetary factors. The author did find that socio-economic factors (race, income, education, etc.) accounted for 20% of the racial mortality gap.

  3. This is a nice study, but obviously the pressing issue is the “why” of compliance. I think sensitivity is also needed here to avoid a “blame the victim” mentality. There is reason to believe that stigma plays a crucial role in driving disparities, and chalking it all up to compliance without further analysis of why compliance is a problem for medically underserved communities runs a significant risk of directing blame to the victims of health disparities. Such an approach would not make for helpful public health policy, IMO.

  4. AnnR says:

    re: ability to pay. Doesn’t the VA offer prescription coverage? I thought they had a formularly list.

  5. […] (RHI) blog today named Healthcare Economist as their Blog of the Week for my post on “Doctors, Patients, and the Racial Mortality Gap.” The RHI Health Blog of the Week is awarded to an exceptional health-related post appearing […]