More than a year in, the Covid-19 pandemic continues to cast light on racial disparities in health care. Two teams of Optum researchers recently published studies using real-world data to explore these disparities in greater detail.
Despite differences in methodology and approach, both studies found that patients of color—and especially Black patients—suffered more severe illness and death from Covid-19 than white patients.
While both studies found that differences in comorbidity burden by race explain some of the observed difference in mortality, they also found that outcomes disparities can't be explained by comorbidities alone. The authors offer several complementary explanations for the observed disparities.
Patients of color were more likely to rely on hospital care
One study used Optum's proprietary large electronic health record database to analyze patient illness and death by race. Based on that analysis, patients of color were more likely than white patients to have their first health care encounter for Covid-19 in an ED or hospital setting.
After controlling for demographics and baseline clinical characteristics, Black patients were 81% more likely than white patients to be hospitalized on initial presentation; Hispanic and Asian patients were 69% and 50% more likely to be hospitalized, respectively.
The findings suggest that patients of color received care later in the course of their illness, often requiring immediate hospitalization or ED care. In addition, a smaller proportion of patients with asymptomatic infection were identified in racial and ethnic minority groups leading to greater risk of disease transmission in these communities.
Black patients were treated at hospitals with higher mortality rates for Covid-19
The other study used UnitedHealthcare-managed Medicare administrative claims data to examine patient mortality and discharge to hospice by race, controlling for patient comorbidities and other characteristics. This study found that a significant portion of the difference in outcomes by race could be attributed to the facility where patients received care.
Black patients were more likely to be treated at hospitals with worse outcomes for Covid-19 than patients of other races. Based on a simulation, the researchers estimated that mortality rate for Black patients would be reduced by 1.25 percentage points if they received care in the same hospitals and in the same distribution as white patients.
Furthermore, the research did not observe any differences in outcomes by race within hospitals, reinforcing that the difference stemmed from treatment differences between hospitals rather than bias in treatment within hospitals.
Our take: health equity challenges will outlast the pandemic
Each of these explanations point to health disparities that will outlast the pandemic.
Patients of color may be more likely to rely on the hospital due to financial barriers or differences in how patients access care. Research from the Kaiser Family Foundation shows that Hispanic and Black patients rely on the emergency department as their primary source of care when sick more than white patients do. Similarly, Hispanic and Black patients are more likely to forestall care due to cost or risk of income loss, which could lead to patients delaying care until their symptoms require a hospital visit.
The difference in outcomes by race may also stem from disparities at the point of care. Black patients experience longer emergency department waiting times and are less likely to receive an urgent Emergency Severity Index at presentation. In the context of the pandemic, that could translate into delayed care for Black patients, leading to later hospitalization rather than appropriate outpatient care.
Differences in where Black patients were treated may stem from residential and historical segregation, with patients accessing conveniently located hospitals for Covid-19 care.
Research from the Urban Institute shows that Black patients are more likely to receive care in hospitals with worse safety conditions—reflecting a disparity extending beyond Covid-19.
In a future post, we'll share our Q&A with the authors of the research on Covid-19 outcomes disparities by facility to discuss this finding in more detail.
What it means for you
We can't ignore the social determinants of health that lead to greater comorbidities and complicate care for patients of color. But at the same time, we also need to address differences in care pathways.
Access constraints that push patients of color to receive care in the ED and hospital lead to worse outcomes, as well as unnecessary spending for plans and high costs for providers. Underinvestment in facilities treating patients from racial and ethnic minority groups exacerbates the outcomes gap.
As you work to improve health equity, watch our Health Equity 101 webinar, which provides the foundational steps to help you get started. Then, check out our research compilation to explore the resources available to you in depth.