Abstract
African American (AA) men remain one of the most disconnected groups from health care. This study examines the association between AA men’s rating of health care and rating of their personal physician. The sample included 12,074 AA men aged 18 years or older from the 2003 to 2006 waves of the Consumer Assessment of Healthcare Providers and Systems Adult Commercial Health Plan Survey. Multilevel models were used to obtain adjusted means rating of health care systems and personal physician, and the relationship of ratings with the rating of personal physician. The adjusted means were 80 (on a 100-point scale) for most health ratings and composite health care scores: personal physician (83.9), specialist (83.66), health care (82.34), getting needed care (89.57), physician communication (83.17), medical staff courtesy (86.58), and customer service helpfulness (88.37). Physician communication was the strongest predictor for physician rating. AA men’s health is understudied, and additional research is warranted to improve how they interface with the health care system.
Introduction
African Americans (AAs), particularly men, suffer disproportionately from preventable diseases (Thorpe, Wilson-Frederick, et al., 2013) and have a higher mortality rate compared to Whites (National Center for Health Statistics, 2007; Rich & Ro, 2002). It is well documented that AAs receive lower health care quality, which may speak to AA men’s disconnect from health care (Bach, Pham, Schrag, Tate, & Hargraves, 2004; Felix-Aaron et al., 2005; Fiscella, Franks, Gold, & Clancy, 2000; Smedley, Stith, & Nelson, 2002; Williams, 2003; Williams & Jackson, 2005). For example, racial and ethnic minorities are more likely to report poor interactions during the medical visit compared to Whites, and this has the potential to affect their use of health services that can enhance health outcomes (Blanchard & Lurie, 2004). Hence, patients’ rating is one important component of their health care experience (Kane & Radosevich, 2008). Additionally, patients’ rating of care is associated with continuity of care, adherence to physicians’ recommendations, and trust in providers (Casagrande et al., 2007; LaVeist et al., 2000; Thames et al., 2012). Consequently, patients’ rating of care is a valued measure of quality health care (Kane & Radosevich, 2008).
Studies examining racial/ethnic differences in quality of health using nationally representative data have been mixed. Analysis of the Consumer Assessment of Healthcare Providers and Systems (CAHPs) Adult Commercial and Medicaid plans reported no significant differences in health care experiences for AAs and Whites (Morales, Elliott, Weech-Maldonado, Spritzer, & Hays, 2001). Lurie, Zhan, Sangl, Bierman, and Sekscenski (2003) reported that AAs rated their care and physicians higher than Whites did; however, AAs reported more difficulties accessing health care and less health services utilization (Lurie et al., 2003). Neither study reported gender specific analyses, which are important to health care quality improvement (Weisman et al., 2000; Weisman, Henderson, Schifrin, Romans, & Clancy, 2001). Additionally, comparative analyses of racial/ethnic differences treat groups monolithically, which also does not provide information on potentially important differences within racial/ethnic populations that are critical to improve health outcomes (Williams, 2005).
Patients’ perception of quality of health care is influenced by gender. Research indicates gender differences in patient satisfaction, predictors of patient satisfaction, and interaction with providers (Allen, Kennedy, Wilson-Glover, & Gilligan, 2007; Cleary, Zaslavsky, & Cioffi, 2000; Felix-Aaron et al., 2005; Weisman et al., 2000; Weisman et al., 2001). Women tend to have better physician communication during the medical encounter and more participatory visits compared to men, which is associated with better health outcomes (Beck, Daughtridge, & Sloane, 2002; Cooper-Patrick et al., 1999; Schoenthaler et al., 2009). Whites report better physician communication than AAs (Blendon et al., 2008). Few studies have examined perceptions of care among AA men. Although research identifies that AA men are less likely than Whites to use primary health care (Smedley et al., 2002), they are even less likely to do so compared to AA women (National Center for Health Statistics, 2011). Moreover, AA men have had less access to culturally competent providers (Allen et al., 2007; Anderson, Scrimshaw, Fullilove, Fielding, & Normand, 2003). The collective experiences of AA men appear to be distinctive from White men and AA women—partly attributable to race- and gender-based differences in economic and social life, health burden, and experiences of inequity in the health care system—which could affect their health care utilization and perceptions of health care (Carpenter et al., 2009; Musa, Schulz, Harris, Silverman, & Thomas, 2009; Williams, 2003; Williams & Mohammed, 2009). Thus, understanding AA men’s perception of health care quality could benefit their health and health-seeking behavior.
The goal of this study was to examine AA men’s health care experience using nationally representative data from the CAHPS, which evaluates multiple dimensions of the health care system ranging from physician communication to customer service helpfulness. This study examines (a) AA men’s ratings of personal physician, specialist, health care, and health plan; (b) AA men’s ratings related to getting care needed, getting care quickly, physician communication, medical/office staff helpfulness, and experience with customer service; and (c) predictors of AA men’s rating of their personal provider.
Method
Study data were drawn from CAHPS Adult Commercial Health Plan Survey 3.0 from 2003 to 2006. The Agency for Health Care Research and Quality initiated CAHPS in 1995 to assess consumers’ experiences with health care (Agency for Healthcare Research and Quality, 2006). Health plan enrollees are sampled from commercial plans, and each sampled enrollee completes a mailed or telephone version of the questionnaire. CAHPS collects data on patients’ health plan type, experiences with health plan and providers/staff, health care visits, and sociodemographics. For each year from 2003 to 2006, CAHPS Adult Commercial Survey included responses from more than 100,000 enrollees, and AAs accounted for around 9% (~9,000) of the annual total with AA men comprising about one third of the responses for AAs. The study sample was limited to AA male respondents from 2003 to 2006 waves of CAHPS. The final analytic sample included 12, 074 AA men aged 18 years and older.
Variables Under Observation
CAHPS 3.0 used two measures for reporting global ratings and composite scores (Agency for Healthcare Research and Quality, 2006). Global ratings assessed areas such as health plan, personal provider, specialist, and health care on a scale of 0 (worst) to 10 (best). An example of a global rating question is, “Using any number from 0 to 10 where 0 is the worst personal physician and 10 is the best personal physician, what number would you use to rate your personal physician?” The composites were composed of five areas, getting needed care (four questions), getting care quickly (four questions), physician communication (four questions), medical/office staff courtesy (two questions), and customer service helpfulness (three questions). Composite scores were grouped according to similar measures and results reported as a big problem, small problem, never a problem or always, usually, sometimes, or never. Examples of composite questions are the following: getting needed care (“Since you joined your health plan, how much of a problem, if any, was it to get a personal doctor or nurse you are happy with?”), getting care quickly (“In the past 12 months, when you needed care right away for an illness, injury, or condition, how often did you get care as soon as you wanted?”), physician communication (“In the past 12 months, how often did doctors listen carefully to you?”), and medical/office staff courtesy (“In the past 12 months, how often did office staff at a doctor’s office or clinic treat you with courtesy and respect?”). Composite construction was completed according to CAHPS guidelines (Agency for Healthcare Research and Quality, 2006). Global ratings and composite scores were converted to a 0 (worst) to 100 (best) scale (Lurie et al., 2003).
The main independent variables of interest for rating of physician(dependent variable) were composite items (physician communication, getting care quickly, getting needed care, medical/office staff courtesy, customer service helpfulness), rating of health plan, rating of health care, number of physician visits, and product type (health maintenance organization, preferred provider organization, health maintenance organization/point of service). Age-groups (18-24, 25-34, 35-44, 45-54, 55-64, 65-74, and 75 or older), educational level, and perceived health status were control variables.
Other independent variables were those related to access and utilization per Lurie et al. (2003) and rating of physician. In CAHPS, respondents were asked the following questions: “Do you have one person you think of as your personal physician?” “In the past 12 months, how many times did you go to a physician’s office or clinic to get care for yourself?” “In the past 12 months, how many times did you go to an emergency room to get care for yourself?” “In the past 12 months, did you or a physician think you needed to see a specialist?” “In the past 12 months, did you see a specialist? What number would you use to rate your personal physician or nurse?”
Statistical Analysis
Analyses were performed using Stata (Version 10.0; StataCorp, 2007). Frequency distributions were completed for AA patients’ demographics to evaluate the control variables across the analytic sample. Multilevel modeling was performed (xtmixed in Stata) to get adjusted means for global rating and composite scores for AA respondents similar to Lurie et al. (2003). Global ratings and composite means were adjusted for age, gender, education, health status, length of enrollment in plan, and health plan random effects(to control for differences due to health plans), per CAHPS suggestions (Agency for Healthcare Research and Quality, 2006). The last multilevel model analysis assessed the association and statistical significance of global ratings and composite scores on rating of personal provider. Results were significant at p < .05.
Results
Characteristics of the Study Sample
The overall percentages for demographic and other variables used in this analysis are presented in Table 1. More than 70% of the men were 35to 64 years old, 63.4% had some college or greater, and less than 8% did not have a high school diploma or equivalent. Approximately 87% reported good, very good, or excellent health, and 53.1% had been in their current health plan for 5 years or more. Having a personal physician was reported by 82.4%, and 61.3% did not have the same physician before joining current health plan.
Demographics of Sample.
The means and standard errors for the global ratings, composite scores, and access and utilization variables are reported in Table 2. The mean ratings for personal physician, specialist, and health care exceeded 80 (on a 100-point scale): 83.90, 83.66, and 82.34, respectively. The mean rating for health plan was 78.87. Most of the composite scores exceeded 80: getting needed care (89.57), physician communication (83.17), medical staff helpfulness (86.58), and customer service experience (88.37). The mean rating for getting care quickly was 59.65. Having a personal physician (87.77) and needing a specialist and seeing a specialist (91.17) were the highest means for access and utilization variables. The mean percentage for no physician visits within the past 12 months was 22.89%, and the mean for emergency room visits within the past 12 months was 24.11%. All means were adjusted for age, general health status, length of enrollment, and health plan random effects.
CAHPS Global Ratings, Composite Scores, and Access and Use Measures.
Note. CAHPS = Consumer Assessment of Healthcare Providers and Systems. Means adjusted for age, general health status, education, length of enrollment, and health plan random effects.
Rating of Physician
A multilevel model was used to examine factors associated with personal physician rating. Participants with higher health care ratings (one unit higher) had higher (0.54) physician ratings (Table 3). Those with better physician communication scores (sometimes, usually, and always) had higher physician ratings (0.93, 1.17, and 1.32, respectively) than those who never had any physician communication (the reference group). AA men who rated medical staff as sometimes helpful had lower physician ratings (−0.742) than those who rated medical staff as never helpful (the reference group). Those who reported customer service as not a problem had lower physician ratings (−0.38) than those who reported customer service as a big problem (the reference group).
Association of Health Care Rating and Composite Scores to Personal Physician Rating.
Note. Model adjusted for age, education, and perceived health status.
Discussion
The study examined health care ratings, utilization, and determinants of personal provider rating of AA men using data from CAHPS Adult Commercial Health Plan Survey 3.0 from 2003 to 2006. The adjusted global means ratings for AA men (on 100-point scale) were mostly above 80 (physician, specialist, and health care), except for the mean rating of health plan at 78. Jha, Orav, Zheng, and Epstein (2008) define high global health care ratings as 9 or 10 (on at 10-point scale). Thus, if one considers a rating of 80 as better than average for ratings, the finding is of some importance considering AA men’s poor access to culturally competent providers (Allen et al., 2007; Anderson et al., 2003), their distrust of the health care system (Boulware, Cooper, Ratner, LaVeist, & Powe, 2003; Corbie-Smith, Thomas, & St George, 2002), and self-reliance (Franklin, 1992; Franklin & Boyd-Franklin, 2000).
The majority of the composite adjusted means (getting needed care, physician communication, medical staff experience, and customer service experience) were greater than 80, except for the composite mean of getting care quickly. The aforementioned findings are not congruent with other research, which identifies that AAs are more likely to report being mistreated during the medical encounter, and greater barriers to health care (Blanchard & Lurie, 2004; Fowler-Brown, Ashkin, Corbie-Smith, Thaker, & Pathman, 2006). Conversely, a study by Weech-Maldonado, Elliott, Oluwole, Schiller, and Hays (2008) using CAHPS data reported higher CAHPS ratings for minority respondents than for other nonminority groups. Our study’s low adjusted composite mean of 59 for getting care quickly by AA men was not unexpected. Managed care studies continue to illustrate problems with access to care overall (Mittler, Landon, Fisher, Cleary, & Zaslavsky, 2010; Povar et al., 2004; Schneider, Zaslavsky, & Epstein, 2002; Scholle, Mardon, Shih, & Pawlson, 2005); nevertheless, the composite mean of 59 was lower compared to previous examination of CAHPS (Lurie et al., 2003).
The other major finding was that physician communication was the strongest predictor of physician rating for AA men. This finding was not expected since AA men appear to be less engaged in the health care encounter with lower active participation in medical decision making and communication compared to other groups (Jernigan, Trauth, Neal-Ferguson, & Cartier-Ulrich, 2001; Katz et al., 2004; Vieder, Krafchick, Kovach, & Galluzzi, 2002). AAs are more likely to perceive discrimination than other groups during the medical encounter (Halanych et al., 2011). Participatory physician visits are associated with higher patient satisfaction and better health outcomes for all groups (Clever, Jin, Levinson, & Meltzer, 2008).
The study has some limitations. Health literacy was not included in this study, and the findings might be affected by these measures (Schillinger, Bindman, Wang, Stewart, & Piette, 2004). Masculinity is another factor not captured by the survey that is an important aspect of health for AA men (Griffith, Gunter, & Watkins, 2012). However, the sample does include educational level of the participants, with more than 60% of the analytic sample having at least some college and 27% having a college degree or more. This is not a representative of AA men in the United States, with less than 10% of AA men having a college degree (U.S. Census Bureau, 2011). Additionally, CAHPS scoring has identified that some racial/ethnic groups tend to engage in higher scoring than other groups (Weech-Maldonado et al., 2008).
Despite the limitations, our study makes a significant contribution to the literature. Patient satisfaction is associated with better health outcomes and more appropriate use of health services; however, no study has examined the health care rating for AA men, a group with significant health issues. AA men tend to rate their health care above 80 (on a 100-point scale), and physician communication is a strong determinant of physician rating. Providers should consider the importance of their communication with AA men and processes to enhance their communication with this group. This is of some importance because AA men appear to have a disconnection from the health care system, and addressing patient communication with AA men might improve their experience. Future research should examine the association of health care rating by AA men and primary health care visits, which can enhance how this group interfaces with the health care system and reduce cost associated with delayed care (Thorpe, Richard, Bowie, LaVeist, & Gaskin, 2013).
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Robert Wood Johnson Foundation.