Is It Racist to Pay Doctors Based on Patient Satisfaction?

Take a moment to ask yourself whether any of these categories describe you or someone you love:

• Never had cancer
• Psychologically distressed
• No regular health care provider
• No health insurance
• Lack confidence in self care
• Avoid doctors
• Minority race

If any of these terms describes you or a loved one, then you are statistically more likely to give a doctor a lower client satisfaction score. When a doctor will earn less by treating you than someone else, how long do you think it will be before you start having a hard time finding a primary care appointment?

Last week, the first article in the "Patients Rating Doctors: Let's Pay Popular People More" series discussed how paying doctors on the basis of client satisfaction surveys may actually undermine the care of our most vulnerable patients, as well as entire systems that struggle to address complex issues.

You might have been thinking that this issue doesn't really affect you personally, other than on some vague, population-based health level. This list should make it clear that it may.

From a health disparities perspective, the most disturbing item on this list is race. Bias and racism (of all types) in medical care have been long recognized. They occur at almost every level and have been extensively studied to try to diminish the impact on population health.

Health disparities exist not just because of lifelong socioeconomic and environmental disparities, but also because of bias in health care. Focused efforts to address issues of racism among providers have measurably improved survival.

Government payouts based on client satisfaction surveys would do the opposite.

Studies show that patients rate same- and majority-race providers higher than minority providers. Patients will state up front that they believe they get better care from a provider of the same race. What's more, a doctor's race influences client satisfaction much more than gender or religion. These differences are so pronounced that there has even been a call to use different questions for African American patients and to throw out the "extreme" results from people with "less educational attainment."

Even leaving out issues of racism, you can just imagine a doctor's perspective: Who wants to take care of a patient who is statistically likely to rate you poorly when your payment for services is based on that same rating? Would cutting payments to doctors who are racially insensitive make them more sensitive and willing to take on more minority patients? Or is it likely to make it even harder for minority patients to get health care?

So why is no one discussing this obvious flaw in satisfaction-based payment?

No one wants to step forward and criticize client satisfaction surveys. Doing so comes across as being anti-patient. But surveys are one thing, and payment is another thing altogether. Paying doctors on the basis of popularity would create, for the first time in any profession, a system that financially rewards racism and bias just as we are beginning to make some small, but significant changes to the huge racial disparities in health care.

And there is another, equally important problem with paying doctors based on popularity. Racism and bias work both ways. There's provider-against-patient bias, but there's also a less talked about patient-against-provider bias. According to both studies and anecdotes, basing payment on client satisfaction surveys can discriminate against minority physicians.

Patient satisfaction is deeply associated with provider race in a complex way. Being the same race as the patient, whatever it is, results in higher satisfaction ratings, which puts minority providers practicing in majority environments (such as academic medical centers) at a huge financial disadvantage.

I discovered in medical school that patient bias against providers is not just a statistical phenomenon, but a painful reality. A medical school classmate - brilliant, kind, and gentle - would be sent, like all of us, into a patient's room to do a "work-up." But her experience was often very different than mine because she is African American, and I am white. For her, the conversation with a patient often began with being forced to explain that no, she wasn't there to empty the trash.

Not once did I ever have to explain that I wasn't supposed to take out the trash.

And it continues on past medical school. Both my minority physician friends in private practice and even some of my neighbors and acquaintances will talk in veiled ways about how patients might not "warm up" to a certain - say, Asian-American - physician. This, we all know at some deep level, is code for a form of racism.

Should our government discriminate against minority doctors because of this bias? Almost no one feels comfortable discussing this. None of us really wants to think about patients being racist. But patients are, after all, us, and we, as a society, are biased in endless, too-numerous-to-count ways.

After all our struggles to get to some degree of equity in our health care and society, why would we start a government-run program with different rates of doctor-payment based purely on popularity?

As our government takes steps to use client satisfaction surveys as a basis for physician payment, we are, as a society, moving toward using our tax dollars to deliberately enshrine and reward bias.

Doctor-blogger Jan Gurley writes for ReportingonHealth, a USC Annenberg School for Communication & Journalism online community for journalists and thinkers. Her blog explores the practice of medicine on the margins of society and what we can learn from it. You can see more of her posts here.

Part 1 of 3: Patients Rating Doctors: Let's Pay Popular People More!

Part 2 of 3: Is It Racist to Pay Doctors Based on Patient Satisfaction?

Part 3 of 3: Patients Satisfaction Surveys: Valid Test, Or Make-Work for Money?

Disclaimer: Identifiable patients mentioned in this post were not served by R. Jan Gurley in her capacity as a physician at the San Francisco Department of Public Health, nor were they encountered through her position there. The views and opinions expressed by R. Jan Gurley are her own and do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.