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An experienced doctor represents more than just years in the field. They are the product of lessons learned and crises navigated, and they offer not just treatment, but informed, battle-tested guidance when it matters most.
But according to research published last month in JAMA Network Open, senior physicians may avoid seeing Black folks, other people of color, and Medicaid-insured patients. Instead, these groups are more likely to be assigned to less-experienced medical professionals.
“It’s a widely known ‘secret’ that in some practices, the older doctors push patients with lower-paying insurance, and by extension patients of minority races to the more junior doctors in their clinic,” Michael Barnett, associate professor of health policy and management at Harvard University’s T.H. Chan School of Public Health and lead author of the study said in a statement.
However, “this is rarely discussed openly,” Barnett said. “Our study finds evidence to back up this hidden practice, which raises concerns of a two-tiered system by physician seniority that promotes racial and economic segregation.”
What the Data Shows
Barnett and his colleagues reviewed athenahealth claims from 2017 and Medicare claims from 2021 — accounting for over 134 million patients and nearly 200,000 physicians. The researchers divided the physicians by practice type — cognitive (e.g. primary care or endocrinology), procedural (e.g. surgical or procedural specialty), and non-office-based (e.g. emergency medicine or radiology) — and reviewed which patients were treated by each group.
Senior cognitive physicians saw 1.6% fewer Medicaid patients and 1.2% fewer racial/ethnic minorities than junior physicians. Senior procedural physicians saw 2.9% fewer Medicaid patients and 1.7% fewer racial/ethnic minorities.
There were no significant differences among non-office-based physicians, who don’t see patients on scheduled visits.
The researchers note that cognitive and procedural physicians may be persuaded to treat fewer Medicaid-insured patients to avoid low reimbursement rates, since they’re paid the highest rates by private insurers. The doctors may also reject Medicaid patients to avoid higher administrative burden.
Patient choice may also contribute to the gaps, the team noted.
Dangers for Black Patients
Quietly ousting patients due to their insurance status can have a rippling effect on Black patients, who rely heavily on Medicaid for healthcare coverage.
In 2021, an estimated 60% of Black children, ages 0-18, and 29% of Black adults, ages 19-64, were enrolled in the program. On the other hand, 33% of white children, ages 0-18, and 17% of white adults, ages 19-64, were enrolled.
Insurance-based discrimination can lead to adverse health effects on those who are turned away. Medicaid patients, who are limited to a small network of providers, may experience delayed care and as a result, increased risk for morbidity and mortality.
It’s unclear whether senior physicians provide higher quality care than junior physicians, Barnett said. As a primary care physician, however, he said many patients prefer a more experienced provider.
“Our study suggests that patients may encounter barriers on who they can see, even in the same practice, based on who they are and what insurance they can afford. Addressing these barriers and widening patient access to all kinds and levels of physicians is essential to a more equitable health care system.”
