Bojangles Effect

05.26.14

How Obamacare Will Screw Black Doctors

By tying doctor pay to patient satisfaction scores, Obamacare’s ‘pay for performance’ system is going to disproportionately hurt minority doctors. Here’s why.

Imagine that you’re an optimistic third-year medical student walking into the ER. Your first patient says to you, “I don’t want any niggers touching me.” There you are in your brand new white coat—the apotheosis of your and your parents’ hopes and dreams—but still, to this patient, you’re a nigger. You try to ignore the sting in your eyes—the shame of it. You suck it up, say nothing, and move on.

This kind of thing has happened to me from time to time—even as a studious, light-skinned offspring of a white father and black mother; even as a person who has “no discernable negro accent”; even as a person who was schooled since I was knee-high to respond to the question of what race I am by saying, “Homo sapiens sapiens because there is no such thing as race.”  

But it turns out that to a lot of people, I’m still a nigger.

Over time, I learned to please people—like anyone would—despite their obvious disappointment when they see that I’m black. I got good at being what people need me to be. But it slowly transformed me into something I couldn’t foresee—a sort of Dr. Bojangles—delighting everyone with my expressive face and tap dancing feet. And although I have been an Obama supporter, it’d be disingenuous if I didn’t conclude that we’re faced with the fascinating paradox that the signature policy of the first black president may indeed serve to increase our racial divides. 

It’s simply a fact of life: Some people are racist. What can you do but adapt and soldier on?

After all, even the most well-intentioned people have unconscious racial biases. In fact, researchers have developed a test that demonstrates that most of us—some 70% or more— have implicit racial bias, no matter how free of prejudice we think we are.

Yet, the influence of race was completely ignored when the government tied patient satisfaction scores to doctor’s pay. We have to ask: In what way will a doctor’s race be financially rewarded or penalized by our government?  

“You only have to be a minority doctor to see why the… [patient satisfaction] score is heavily stacked against you,” one internist reported in a recent Medscape article, “Is Placating Patients Putting Medicine in Peril?”  “If you [work] in a predominantly majority area...for minority doctors, the [patient satisfaction] score has really been a major disaster.”   

As physician-health-care blogger Dr. Jan Gurley wrote about her experience at Harvard Medical School, “A medical school [classmate’s]…experience was often very different than mine because she is African-American, and I am white. The conversation with a patient often began with being forced to explain that no, she wasn’t there to empty the trash.”

In fact, patients’ racism against providers has been called medicine’s “open secret,” but it’s difficult to address because patients don’t usually walk through the door snarling racial epithets. As one African-American physician confided to me, “Although most racial slurs are not as direct as ‘I don’t want any niggers touching me,’ it still means the same when one hears  ‘Are you the doctor?’ or ‘When will the real doctor be here?’”

These so-called “micro-aggressions” are a frequent occurrence for many black doctors. My own career has been punctuated by several stupefying moments where patients start talking about niggers—in private behind the curtain or, humiliatingly, in full view of the trauma team. But for black doctors to get to the top 1 to 2% in patient satisfaction—like I did when I worked in assembly-line medicine—it requires a certain talent to combat those relentless micro-aggressions.

And that talent involves developing empathy for the racist. I might observe, for example, the patient’s face fall with disappointment, the brow knit with worry when they lay eyes on me. While I field their questions about how well I did in school, I’ll reassure them they aren’t dealing with any ordinary Negro—amazing them with flourishing displays of medical knowledge and boundless kindness. It’s an exhausting and unrelenting Bojangles’ routine—requiring every ounce of intellectual and emotional skill to both soothe and delight—and it’s repeated anew three or four times an hour. It’s a lot to ask of anyone—let alone someone earning $10 for the patient visit. I’d wager that most white doctors don’t experience patient care quite like this. But it would be wrong to imply that white and so-called “model minority” physicians aren’t also the victims of patient racism.

Indeed, while Mrs. Obama exhorts us to talk about racism, we might start by accepting that we all have racial biases. And we all have racial biases because human beings are pattern-forming creatures. But in my experience, the least racist people openly acknowledge that they have those “patterns” and work hard to correct them when they are wrong or unfair.

Bias against black doctors is indeed unfair, because studies have failed to show that a physician’s race affects patient outcomes. On the other hand, numerous studies have shown that patients are more satisfied with doctors of the same race. Indeed, one study showed that black patients with black doctors were 140% more likely to rate their physician as excellent than if they had a doctor of another race. White patients with white doctors were 63% more likely to say they felt their doctor listened well. And Hispanic patients with Hispanic physicians were 74% more likely to feel satisfied overall with their care.

This implies that under the current patient satisfaction scheme, all physicians—not just black physicians—may be penalized financially on the basis of race.  

Consider how this plays out in real life as opposed to a think tank. A hard-working doctor (of any race) has rendered careful, considerate care to a complicated patient. Yet a relative who gets the patient satisfaction form in the mail who might be pissed off at, say, the hospital parking fees—or maybe doesn’t like the color of the doctor’s skin—will determine how well the doctor gets paid, or even if he keeps his job.

And apparently that’s OK with our government.

It should go without saying that our government has no business promoting a program like this and it should be stopped. But it’s on track to get worse with Obamacare’s “pay for performance” that will withhold even more Medicare payments for low patient satisfaction scores. This financial threat is already causing unethical administrators to pressure doctors to compromise their professional standards to order unnecessary meds and tests to bump satisfaction scores.

If administrators already engage in this unscrupulous behavior, we have to wonder if race will influence future hiring policies. Even for hospitals serving minority populations—if black patients are more than twice as likely to think a black doctor is excellent—it wouldn’t make any sense to hire white doctors at all.  

Obamacare, with its focus on patient satisfaction, will penalize doctors on the basis of race, and may very well racially segregate doctors who swore a solemn oath to provide health care to all our citizens. It’s not that far-fetched, because even from the physician’s perspective, it simply doesn’t make sense to opt to take care of patients who are biased against them. Indeed it’s been shown that the patients who tend to give lower scores to physicians are those characterized by “minority race, psychological distress…not having a regular health care provider, not having health insurance.”

So while disadvantaged minorities with these characteristics are often most in need of good medical care, the government has misaligned the economic incentives to take care of them.  Paying doctors on the basis of popularity would create, for the first time in any profession, a system that financially rewards racism and bias,” wrote Dr. Gurley in “How Paying Doctors for Patient Satisfaction is Racist.”

To be sure, in an increasingly transparent world, patient satisfaction scores could deliver useful information. But this program is not good enough for the American people. Indeed, the surveys could help physicians improve cross-cultural communication—instead of financially penalizing them for even trying. But by tying patient satisfaction to hospital and physician pay—the government has invoked the law of unintended consequences.

That law discriminates against doctors on the basis of race. That law incentivizes doctors to turn away minorities. That law encourages doctors to opt out of Medicare—shrinking access to care. You could even say that law increases the Bojangles’ effect—forcing physicians to smile obsequiously, while writing orders they don’t believe in, for patients they’ll increasingly grow to resent.