Elements of the Health Care Eco-Sytem that Pose as Barriers to Care Week 5 Written Assignment
1. RunningHead: Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
Elements of the Health Care Eco-System that Pose the Biggest Barriers to Care
Ardavan A. Shahroodi
Professor James J. Ferriter
HMG 6110- The Organization, Administration, Financing and History of Health Care in the
Week 5 Written Assignment
Thursday, May 8, 2013
2. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
Barriers to care permeate our system of health care. These barriers exist not only rooted
in the people’s inability to secure basic health insurance. Many factors such as racial/ethnic,
financial/economic, social, cultural, diagnostic and organizational variables also potentially
hinder access to care. The introduction of the Affordable Care Act is meant to address the worst
of the inadequacies persisting in our health care eco-system. However, the elimination of other
barriers entails concerted multi layered campaigns in order to create accountable health care
Lack of Health Insurance as a Barrier to Care
Barr (2011) informs us that in 2009, “83.3 percent of Americans had some form of health
insurance coverage” (p. 253). He adds that “The remaining 16.7 percent of Americans-50.7
million people-faced the prospect of illness or injury with no health insurance, however, and thus
no way to pay for their health care” (p. 253). In a most significant observation, Barr (2011) also
shares with us that the above estimate of the uninsured is only pertaining to those Americans
who possessed no insurance for the entire year (p. 253). As the matter of fact, Barr (2011)
asserts that “An even higher percentage went without health insurance for at least part of the
year” (p. 253).
In addition to those who are uninsured in this country, “people who change jobs” (Barr,
2011, p. 256), college students “between graduation and beginning employment” (Ibid) and self-
employed people who cancel with one insurance and “enroll with a new insurance carrier” (p.
257) experience a lack of insurance for a portion of the year. As a matter of fact, Barr (2011)
states that, “Two-thirds of uninsured Americans are families with annual household income
3. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
above $25,000.” (p. 256). In addition, 41 percent of the uninsured are between 18 and 34 years
old and 15 percent of the uninsured are children with 47 percent of the uninsured being white, 16
percent black and 32 percent Hispanic (Barr, 2011, p. 258).
One of the most significant aspects of the uninsured dilemma is that “the problem…is
principally a problem of working families” (Barr, 2011, p. 258). According to Barr (2011), in
2009, 31 percent of the uninsured were unemployed, 34 percent were fully employed during the
year and 35 percent were part time employees (pp. 258-259). Barr (2011) argues that “the
problem of the uninsured is not primarily a problem of the poor and the unemployed. It is a
problem of middle class, working families” (p. 260). This is indeed a sobering observation! We
must be cognizant of the fact that employment (full or part-time) does not automatically result in
being covered with health insurance. In addition, some workers opt out of participating in work
related insurance due to factors such as cost, high deductibles/premiums (out-of-pocket
expenses) and inadequate coverage. Many low wage workers simply may not be able to afford
enrolling in health insurance through their employers. Furthermore, with respect to small size
employers, “The cost of providing health insurance to these workers can be prohibitive” (Barr,
2011, p. 261).
Probably the single most important characteristic of the Affordable Care Act (ACA) is the
extension of health care insurance coverage to “all citizens and permanent residents” (Barr,
2011, p. 271). ACA contains multiple vehicles that facilitate the subsidization of health
insurance coverage for different categories of low income individuals and families. ACA also
“requires states to establish health benefit exchanges” (Barr, 2011, p. 271) in order to “assure
that affordable, private health insurance coverage is available to all those who wish to purchase
it” (Ibid). The adoption of ACA is by far both symbolically and in concrete terms the most
4. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
significant historical development in the field of health care since the creation of the Medicare
program in the 1960s and early 1970s.
Additional factors that Pose as Barriers to Care
A number of barriers that restrict an individual’s ability or sections of the population
from acquiring health care or for that matter quality care in the U.S. are not related to insurance
carrying status. As Barr (2011) states, “These barriers generally stem from forces within the
organizational environment of the health care delivery system or within the broader social
system itself” (p. 273). The following is a list of a number of such barriers that may prevent or
adversely affect the quality and effectiveness of needed care in certain population groups and
Particular characteristics of insurance coverage and their ability to cover urgent care
Braveman et al. (1994) compared four groups of patients with each other that suffered
from acute appendicitis. These were patients with “traditional fee-for-service insurance” (as
cited in Barr, 2011, p. 274), patients with insurance “through a health maintenance organization
(HMO)” (Ibid), “patients with Medicare” (Ibid) and “patients with no health insurance” (Ibid).
The study found that patients with “Medicaid or no insurance had approximately a 50 percent
greater risk of developing a ruptured appendix than patients with HMO coverage” (as cited by
Barr, 2011, p. 274) and patients “with fee-for-service insurance were at a 20 percent greater risk
of developing a ruptured appendix than those with HMO coverage” (Ibid). The conclusion
points to the fact that those who have no insurance or must rely on Medicaid for insurance
coverage usually do not have their own Primary Care Physician (PCP) and as a result utilize the
5. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
emergency room of “large, often crowded hospitals to obtain care for urgent problems” (Barr,
2011, p. 274). Barr (2011) refers to this as “Lacking a regular source of care” (p. 274).
However, how about those patients who were enrolled in traditional fee-for-service
insurance and their tendency of developing a ruptured appendix 20 percent more than those
patients that belong to a HMO? Barr (2011) asks “Why would patients with full insurance have
problems obtaining prompt diagnosis and treatment for acute appendicitis?” (p. 274). Here he
argues that patients with HMO insurance usually must select a given PCP at the time of joining
that Health Maintenance Organization. Although patients with a traditional fee-for-service
insurance might delay selecting their own PCP and consequently this is a matter of convenience
and greater facilitation in locating a PCP on the part of a HMO. Barr (2011) contends that
“Having a previously identified provider can facilitate obtaining care in an urgent situation” (p.
275). There is also the additional factor that those who belong to a HMO usually pay a lower
deductible and co-payments than those who belong to a fee-for-service insurance that “may lead
to patients delaying necessary care” (Barr, 2011, p. 275). Barr (2011) concludes that “For
patients with health insurance coverage, the type of insurance may affect the accessibility of
care, with potential adverse health consequences” (p. 275).
An additional factor that here poses a barrier and challenge to the quality and proactive
delivery of care is the burden placed on hospital emergency rooms in order to cater to those that
utilize their services for routine care purposes. As mentioned in the aforementioned paragraphs
these are the patients with no insurance, Medicaid or fee-for-service insurance. As an example,
Barr (2011) mentions that between 1999 and 2007, Medicaid patients utilized hospital
emergency room services by an increase of 37 percent.
6. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
The solution to the above predicaments seems obvious. Every effort must be made in
order to bring those who have no health insurance under the umbrella of full coverage.
Affordable Care Act (ACA) utilizes a number of programs in order to offer health insurance to a
variety of population groups. ACA also will “provide for an increase in reimbursement for
primary care physicians who treat Medicaid patients” (Barr, 2011, p. 293). I will address both
these efforts in future sections. Furthermore, an intensive effort must be made in this country to
expand the role of PCPs as promoters of health, healthy existence, prevention and health
education for their patients. PCPs must be given the added resources commensurate with this all
important mission of health promotion. In short, we must bring glamor, honor and prestige to
the indispensable mission of a PCP. Once more patients are under the active management and
supervision of their respective PCPs concerning healthy life choices and prevention, many acute
health conditions will also be alleviated and the over burdening of the hospital emergency rooms
will also addressed.
Out-of-Pocket Health Related Expenses as Barriers to Care
In order to evaluate if out-of-pocket expenses effect the frequency that patients seek care,
the Rand health insurance study was conducted taking into consideration patients who paid
different amounts of co-insurance rate. Here, Newhouse et al. (1981) found that indeed there
exists “an association between the amount a patient must pay and the frequency with which the
patient will obtain care” (as cited by Barr, 2011, p. 275). As Barr (2011) states “when a patient
is responsible for paying for part of the cost of care, he or she is less likely to use that care. This
association applies to necessary care as well as to unnecessary care” (p. 276).
The implications of this finding are indeed extremely complicated. In an era, when as
Sisko et al. (2010) have estimated, the amount of health care expenditures in our society in 2010
7. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
“represented 17.3 percent of GDP” (Barr, 2011, p. 19) with the specter of ever increasing health
care expenses looming in the horizon, any potential cost saving opportunities must be thoroughly
investigated. Here, I err on behalf of those who advocate a voluntary system in which patients
are allowed to increase or decrease the amount of their co-insurance rates, premiums and
deductibles in commensurate with their financial or health related needs. That is, these
individuals exercise their own judgment and free choice in determining the amount of their out-
of-pocket expenses. However, I strongly advise against the creation of involuntary systems
where needed care is actively made unavailable or unreachable based on prohibitive out-of-
pocket expenses such as high co-insurance rates, premiums and deductibles.
Medicaid Coverage as an Inadequate Protection of Health and a Barrier to Care
In his observations, Barr (2011) contends that “low reimbursement rates” (p. 277) causes
many physicians not to accept Medicaid patients into their practice. He also adds that such a
situation leads to the unavailability of potential doctors in certain communities and the creation
of an environment where Medicaid beneficiaries have no recourse but to use extremely busy
hospital emergency rooms in order to seek and receive basic treatment for routine care (Barr,
2011, p. 277). In their research, Braveman et al. (1994) found that Medicaid patients who
suffered from Appendicitis had a 50 percent more of a chance to develop a ruptured appendix
than those patients that belonged to a health maintenance organization (HMO) (as cited in Barr,
2011, p. 277).
Barr (2011) also shares with us the result of some other studies comparing the service
that Medicaid patients receive to the service experienced by those patients with private insurance
(pp. 277-278). In one study called the “Medicaid Access Study Group” (1994), researchers
recorded how quickly Medicaid patients were able to secure an appointment for minor
8. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
complications in comparison to patients with private insurance (as cited by Barr, 2011, p. 278).
In this particular study, 60 percent of times, patients with private insurance were able to secure
an appointment to be seen by a physician in a matter of two days. Although those with Medicaid
insurance were able to secure such an appointment only 35 percent of times with other Medicaid
patients being able to secure an appointment to be seen by a physician at any time 44 percent of
In a further study, Asplin et al. (2005) found that patients (trained graduate students) with
private insurance who had endeavored to secure an appointment to be seen for addressing a
“potentially serious medical problem” (as cited in Barr, 2011, p. 278) with “potentially serious
consequences” were able to secure an appointment 64 percent of the time. Within the parameters
of the same experiment, patients with Medicaid insurance were able to secure an appointment 34
percent of time and those with no insurance were able to secure an appointment 25 percent of
time. Interestingly, those patients with no insurance who stated “they would bring full payment
in cash on the day of the visit were able to get an appointment 63 percent of time” (as cited in
Barr, 2011, p. 278).
Under ACA, the structure of Medicaid will be altered by “making benefits available to all
people who are poor, regardless of health status or family status” (Barr, 2011, p. 189). In
addition, “ACA makes Medicaid analogous to Medicare, in that it will provide the same level of
benefits to all those in poverty” (Barr, 2011, p. 189). In regards to low reimbursement rates,
ACA has mandated that physicians “providing care to a patient on Medicaid will be paid at the
same rate as would be paid under the Medicare program” (Barr, 2011, p. 190). In addition, ACA
will support a major expansion of “nonprofit, community-based clinics” (Barr, 2011, p. 190) in
order to accommodate a major influx of new enrollees into the Medicaid program. This last
9. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
item together with higher reimbursement levels will remove major barriers that Medicaid patient
face on a daily basis in their search for securing quality laden, effective and sustainable health
care. This will also lessen the burden that for years has been leveled at the door of hospital
Racial Barriers that Compromise Access to Care
Barr (2011) argues that in spite of major reforms at desegregating the health care system,
intractable problems remain curtailing or compromising quality health care for African
Americans. In one study involving patients seeking care for cardio vascular ailments in VA
hospitals, Peterson et al (1994) found that in revascularization treatments, “Blacks were 33
percent less likely than whites to undergo cardiac catheterization” (Barr, 2011, p. 280). In
addition, researchers found that blacks received 42 percent less angioplasty procedures, 54
percent less coronary artery bypass graft surgery (CABG) procedures and 54 percent less
revascularization procedures than white patients (Barr, 2011, p. 280). The conclusions of this
study also found that “surviving black patients had more chest pain and a lower quality of life
than white patients” (p. 280).
In other studies, Kahn et al. (1994) and Ayanian et al. (1999b) found that black patients
with serious medical issues including heart disease experienced “less aggressive and lower-
quality care” than white patients regardless of their health insurance (as cited in Barr, 2011, p.
280). In addition, Bach et al. (1999) found that black patients with early-stage lung cancer
experienced treatment “less aggressively” (as cited by Barr, 2011, p. 280) than white patients.
Furthermore, Ayanian et al. (1999a) established that black patients were less likely to be
considered for kidney transplantation (as cited in Barr, 2011, p. 280) than white patients. In
another study Boyce (2000) found that blacks were less likely to receive “bone marrow
10. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
transplantation” (as cited by Barr, 2011, p. 280) than white patients. Interestingly in further
studies Todd et al. (2000) and Todd, Samaroo and Hoffman (1993) found that black and
Hispanic patients that “receive emergency treatment for broken bones receive less pain
medication” (as cited in Barr, 2011, p. 281) than white patients.
The above litany of study after scientific study is evidence that “black patients receive
less aggressive and lower quality medical care than white patients with the same disease” (Barr,
2011, p. 281). In search of finding answers to this predicament involving unequal care, The
Institute of Medicine of the National Academy of Sciences conducted a massive study of
“several hundred published research reports” (Barr, 2011, p. 281). In this massive study,
Smedley, Sith and Nelson (2003) concluded that “disparities” (Barr, 2011, p. 281) in care result
from a variety of factors such as the patient’s approach and preferences with respect to medical
care, language and cultural barriers and the physician’s exercise of bias and racial stereotypes ,
“either conscious or unconscious” (Ibid).
Barr (2011) offers two possible explanations in order to understand the exercise of bias
on behalf of the medical profession when offering care to racial minorities (pp. 282-284). First,
Barr (2011) argues that “in attributing the likelihood of noncompliance to a patient based on
racial grouping” (p. 283), the physician may decline the pursuit of more aggressive treatments.
Here, Barr (2011) emphasizes the importance of “treating people as individuals in matters as
crucial as the availability of organ transplantation” (p. 283). Barr (2011) refers to this
phenomenon as “statistical bias” (pp. 282-283).
Barr’s (2011) second explanation labeled as “unconscious bias” (p. 283) utilizes a
number of studies such as the one by Van Ryan and Burke (2000) that hold, “physicians, without
necessarily being conscious of personal bias, react differently to patients of different races” (as
11. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
cited by Barr, 2011, p. 283). As Smedley, Sith and Nelson (2003) have asserted, “bias,
stereotyping, prejudice …on the part of the health care providers may contribute to racial and
ethnic disparities…Stereotyping and bias may be conscious or unconscious, even among the well
intentioned” (as cited in Barr, 2011, p. 284)
Racial prejudice, stereotyping and bias are hallmarks of many societies. We have made
incredible strides in improving race relations in this country and we must still do more with the
exercise of continuous campaigns in reducing bias and prejudice. We may begin with teaching
medical students and practicing physicians for that matter the all-important habit of treating their
patients as individuals first and foremost. Patients regardless of racial and ethnic backgrounds
need and expect the exercise of aggressive, enthusiastic and unbiased care on the part of their
physicians in order to treat their maladies. Feedback, follow through and patient satisfaction
related surveys are also incredibly effective tools in detecting and addressing the practice of bias
and prejudice in medical care.
Living Conditions, Geography, Culture and Diagnosis as Barriers that may Hinder Access
Barr (2011) proposes that living conditions such as being susceptible to asthma attacks
affects patients’ access to routine care. Lozano, Connell and Koepsell (1995) comparing
children who lived in the same city and with the same insurance coverage found that “black
children went to the doctor’s office less frequently yet had higher use of the emergency room and
the hospital” (as cited by Barr, 2011, p. 285). A second study by Rosenstreich (1997)
determined that poverty induced living conditions led the “parents of black children relying more
on the emergency room for care than the doctor’s office” (as cited by Barr, 2011, p. 285).
12. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
Barr (2011) also reminds us that geographical location of the patient may potentially
hinder access to care especially in regards to those living in rural and inner city areas (p. 286). In
the case of rural areas, hospitals are facing increasing difficulty to “survive financially” (Barr,
2011, p. 286). In addition, patients in inner city and economically disadvantaged neighborhoods
face issues dealing with “transportation, arranging child care, and taking time off work” (Barr,
2011, p. 286) that hinder their access to care.
Culture and linguistic differences may also create barriers that may compromise access to
care. Barr (2011) inform us that U.S. Department of Health and Human Services has issued
standards that “all health care providers who receive federal funds are required to adhere to” (p.
287). These standards require that health care providers offer interpreter servicers and other
linguistic accommodations at no cost to all their patients. However, Blendon et al. (2007) found
that in spite of these efforts in improving communication “20 percent of Mexicans, Puerto Rican,
and Central/South Americans as well as Vietnamese Americans felt that they receive poor care
because of their inability to speak English” (p. 287). Again, removing this barrier to care is
related to intensive training of health care professionals not only in matters pertaining to the
medical aspects of providing care but also in the psychological, sociological and racial/cultural
sensitivity aspects of being a health care provider.
An extremely important barrier to care applies to those patients that suffer from Acquired
Immune Deficiency Syndrome (AIDS) and the hesitation of some health care providers to treat
these individuals. The same issue regarding access is experienced by those who suffer from
mental illness or conditions related to substance abuse. These are incredibly important matters
that are being increasingly faced with growing populations of patients in this country. The
13. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
associated costs of not addressing the lack of care that the aforementioned patients experience in
coming to term with their suffering will have incalculable consequences for our society.
Organizational Dynamics as Barriers to Care
In general, our delivery of health care has moved from one operated by “independent
health care professionals” (Barr, 2011, p. 288) to an environment where “large systems of care”
employ many individuals and teams. Barr (2011) argues that especially in primary care, patients
hope for “humanistic behavior by physicians…caring interpersonal interaction with other
employees…continuity of care…accessibility of care…physician satisfaction with work
conditions” (p. 288). Barr (2011) refers to these qualities as the “humanistic competence” of
PCPs. However, Kenagy, Berwick, and Shore (1999) in reflecting on the “managed care
revolution” (Barr, 2011, p. 289) argue that “Our patients want high quality service and do not
believe they receive it” (as cited in Barr, 2011, p. 289).
Barr (2011) offers us a fascinating analysis searching for clues in understanding the roots
of this “humanistic” (p. 289) incompetence prevalent in many sectors of the medical profession.
Barr (2011) contends that in managed care environments, efficiency that is “measured as units of
production per units of time (for example, patients seen per hour)” (p. 290) is paramount. Here,
Barr (2011) refers to the difficulty of offering “high quality human service while under pressure
to be efficient” (p. 290). This he describes as a “role conflict: the conflict faced by a worker
caught between the patient’s desire for good service and management’s emphasis on efficient
work” (Barr, 2011, p. 290). An additional factor found by the research of Chang et al. (2006)
contends that patients evaluated the quality of “doctor-patient communication …associated with
their overall rating of the quality of care” (as cited by Barr, 2011, p. 291).
14. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
The aforementioned dynamics regarding issues dealing with customer
service/satisfaction, performance and quality have been part and parcel of modern organizational
theory and investigation. Most of these issues are settled through the introduction of
empowerment principles and enhancing employee motivation through the usage of non-monetary
incentives such as expanding and promoting creativity and independence in the work place. The
single most significant element in the success of these principles is the commitment of the
respective organizational leadership to their full or partial implementation.
Barriers to care include both insurance and non-insurance related factors. In relation to
insurance oriented barriers, the majority of the uninsured are from middle income working
families who are either unable to secure insurance through their place of employment or are
unable to afford the coverage due to the cost of premiums. Racial/ethnic minorities and the
young represent a significant population of the uninsured. In regards to non-insurance related
barriers to care, factors such as types of coverage, out-of-pocket expenses, the inadequacy of the
Medicaid coverage, racial/ethnic/economic/social/cultural/diagnostic and organizational factors
hinder access to care. The Affordable Care Act (ACA) aims to alleviate the severity of the effect
that many of the aforementioned variables leave in people’s lives. In relation to other barriers
and variables, intensive individual, national and organizational effort is necessary in order to
rectify these inconsistencies.
15. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
Asplin, B. R., Rhodes, K. V., Levy, H. et al. (2005). Insurance status and access to urgent
ambulatory care follow-up appointments. JAMA 294:1248-54.
Ayanian, J. Z., Cleary, P. D., Weissman, J. S., and Epstein, A, M. (1999a). The effect of
patients’ preferences on racial differences in access to renal transplantation. New
England Journal of Medicine 341:1661-69.
Ayanian, J. Z., Weissman, J. S. Chasen-Taber, S. and Epstein, A.M. (1999b). Quality of care by
race and gender for congestive heart failure. Medical Care 37:1260-69.
Barr, D. A. (2011). Introduction to U. S. Health Policy: The organization, financing, and
delivery of health care in America (3rd ed.). Baltimore, MD: The Johns Hopkins
Blendon, R. J., Buhr, T., Cassify, E.F., et al. (2007). Disparities in health: Perspectives of a
multi-ethnic, multi-racial America. Health Affairs 26(5):1437-47.
Boyce, E. A. (2000). Access to bone marrow transplants for multiple Myeloma patients: The
role of race. Undergraduate thesis, Program in Human Biology, Stanford University.
Braveman, P., Schaff, V. M., Egerter, S., Bennett, T., Schecter, W. (1994). Insurance related
differences in the risk of ruptured appendix. New England Journal of Medicine 331:444-
Chang, J. T., Hays, R. D., Shekelle, P. G., et al. (2006). Patients’ global ratings of their health
care are not associated with the technical quality of their care. Annals of Internal
16. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
Kahn, K. L., Pearson, M. L., Harrison, E. R., et al. (1994). Health care for black and poor
hospitalized Medicare patients. JAMA 271:1169-74.
Kenagy, J. W., Berwick, D. M., and Shore, M. F. (1999). Service quality in health care. JAMA
Lozano, P., Connell, F. A., and Koepsell, T. D. (1995). Use of health services by African
American children with asthma on Medicaid. JAMA 274:469-73.
Newhouse, J. P., Manning, W. G., Morris, C. N., et al. (1981). Some interim results form a
controlled trial of cost sharing in health insurance. New England Journal of Medicine
Peterson, E. D., Wright, S. M., Daley, J., and Thibault, G. E. (1994). Racial variations in cardiac
procedure use and survival following acute myocardial infraction in the Department of
Veterans Affairs. JAMA 271:1175-80.
Rosenstreich, D. L., Eggleston, P., Kattan, M., et al. (1997). The role of cockroach allergy and
exposure to cockroach allergen in causing morbidity among inner-city children with
asthma. New England Journal of Medicine 336:1356-63.
Sisko, A. M., Truffer, C. J., Keehan, S. P., et al. (2010). National health spending projections:
The estimated impact of reform through 2019. Health Affairs. 10.377/hlthaff.2010.0788,
published online September 9.
Smedley, B. D., Sith, A. Y., and Nelson, A. R., eds. (2003). Unequal treatment: Confronting
racial and ethnic disparities in health care. Washington, D.C.: National Academies
17. Elementsof the HealthCare Eco-SystemthatPose the BiggestBarrierstoCare
Todd, K. H., Deaton, C., D’Adamo, A. P. and Geo, L. (2000). Ethnicity and analgesic practice.
Annals of Emergency Medicine 35:11-16.
Todd, K. H., Samaroo, N., and Hoffman, J. R. (1993). Ethnicity as a risk factor for inadequate
emergency analgesia. JAMA 269:1537-39.
Van Ryan, M. & Burke, J. (2000). The effect of patient race and socioeconomic status on
physicians’ perceptions of patients. Social Science and Medicine 50:813-28.