Exploring the Current State of Racial and Ethnic Minorities in Healthcare Leadership

Increased racial and ethnic diversity in healthcare contributes to improved access to care, patient experience, and public health, notably for minority populations, and the shift to value-based medicine has increased its importance for both small medical practices and large integrated delivery systems.(1-6) However, diversity in healthcare in the United States continues to reflect poorly on national racial and ethnic demographics.

African Americans, Latinos, and Native Americans are significantly underrepresented in most health occupations, including health diagnosing and treating occupations.(7) Such lack of representation becomes more pronounced in healthcare leadership among physicians and non-clinicians.

However, literature that discusses the specific challenges for attaining meaningful diversity in healthcare leadership is lacking, and the solutions for organizations looking to make improvements remain elusive.

Current Healthcare Leadership Environment

The complexity of healthcare administration, reimbursement, and information technology has aided in the growth of large integrated healthcare delivery systems, new healthcare consortiums, and organizational mergers. Healthcare is now nearly one-fifth of the U.S. gross domestic product, and its major players have leadership infrastructures that mirror other corporate environments.

The number of physicians in the United States grew 150 percent between 1975 and 2010 while the number of healthcare administrators grew 3,200 percent.(8) Physicians are also taking part in healthcare leadership, and many physicians are opting for MBAs and other leadership training.(9) New and enhanced skillsets are evolving for the successful healthcare executive, requiring both strategic and operational lenses.

Racial and ethnic minorities are projected to be the majority population in the United States by 2045.(10) Despite the increasingly multicultural populations served by U.S. healthcare providers, healthcare organization C-suites and boardrooms all too often do not reflect the communities they serve. Racial and ethnic minorities remain significantly underrepresented in healthcare management and leadership.

A 2015 survey by the American Hospital Association’s Institute for Diversity in Healthcare Management found that while racial and ethnic minorities represented 32 percent of patients in hospitals, they comprised only 14 percent of hospital board members, 11 percent of executive leadership, and 19 percent of mid-level and first-level managers.(11)

Gaumer and Coulam report that racial and ethnic minorities constitute 14 percent of top-level managers and officials in private U.S. hospitals; for nonhospital healthcare organizations, the proportion is noted to be 20 percent. Among racial and ethnic minority managers and officials in hospitals, there is considerable geographic variation based on local population size and region, with 30 percent being concentrated in New York, Los Angeles, Chicago, and Philadelphia.(12)

The American Association for Physician Leadership (AAPL) began offering a Certified Physician Executive (CPE) certification for physician leaders in 1997. Since its inception, more than 3,300 physicians have earned CPEs to enhance their careers by obtaining what is considered a competitive advantage in the healthcare leadership landscape.

Racial and ethnic data has not been collected consistently; however, the available data are consistent with non-physician national healthcare leadership trends: 72.2 percent of CPEs identify as Caucasian, compared to 4.4 percent as Hispanic, and 6.8 percent as African American (see Table 1 and Figure 1).

Figure 1. Total CPE by ethnicity from 1997 to 2019

Trends in Academic Medicine

Racial and ethnic minority leadership trends in academic medicine are similar to those seen throughout the rest of healthcare where leadership is predicated largely on achievement of academic rank. The underrepresentation of racial and ethnic minority groups in the physician workforce, even more disparate representation among U.S. medical school faculty, and relatively low numbers of racial and ethnic minorities with senior academic rank all thus directly contribute to poor racial and ethnic minority representation in academic medical center leadership.

Currently, just 6 percent of U.S. medical school graduates are Black or African American; Latinos represent only 5 percent. The numbers among full-time faculty are even more disproportionate: More than 75 percent of full-time U.S. medical school faculty are White or Asian, and in contrast, 4 percent are Latino, 3 percent are Black or African American, and a mere 0.1 percent are Native American.(13)

Racial and ethnic minority faculty are less likely than White faculty to hold senior academic rank. Palepu, et.al., found that Black, Latino, and Asian U.S. medical school faculty are more likely to hold instructor or assistant professor rankings than are White faculty. Conversely, Black, Latino, and Asian U.S. medical school faculty were less likely than Whites to hold associate professor rankings and full professor rankings.(14)

A study by Abelson and colleagues in the American Journal of Surgery found that Blacks accounted for just 2.5 percent of associate professors and 2 percent of full professors in academic surgery programs, noting a decreased rate of the former in the proceeding 10 years. The numbers for Latino faculty were similar: 5 percent of associate professors and 4 percent of full professors.(15) Yu, et.al., examined data on faculty at U.S. medical schools between 1997 and 2008 and found that 88.26 percent of chairpersons and 91.28 percent of deans were White. The respective numbers were 2.69 percent and 4.94 percent for Blacks; 3.37 percent and 2.91 percent for Latinos; and 3.52 percent and 0 percent for Asians.(16)

Benefits of Diversity in Healthcare Leadership

Racial and ethnic diversity in healthcare leadership has both financial and clinical benefits (see Table 2). A 2015 McKinsey & Company report on diversity in public companies concluded that companies that are more racially and ethnically diverse are more likely to yield above-average positive financial returns, and increased racial and ethnic diversity among the senior executive team has a positive correlation to financial performance.(17) Similar statistically significant trends were published by McKinsey & Company in 2018.(18)

A report by Witt/Kieffer showed that diversity in healthcare leadership contributes to successful decision making and to the organization reaching strategic goals. More specifically, leadership diversity was linked to successful population health initiatives and the incorporation of multiple unique perspectives obtaining consensus.(19) Similarly, a 2018 B.E. Smith Team report noted that diverse leadership in healthcare contributes to pay equity, thereby promoting productivity and retention, which are additional financial benefits.(20)

With racial and ethnic minorities on pace to exceed half of the U.S. population within the next 25 years, diverse leadership in healthcare has several clinical benefits, two of which are patient outreach and targeting of care, both contributing to health equity and outcomes. Enhanced data analytics and the ability to influence social determinants of health are also benefits attributed to having healthcare leadership diversity.

Finally, healthcare leadership diversity can optimize patient navigation of health services and improve utilization. This occurs as a byproduct of improved patient and community engagement; promotion of trust and confidence; and removal of perceived barriers between the healthcare system and minority communities.(20)

Recommendations for Healthcare Firms

Per Witt/Kieffer, the barriers to improving healthcare leadership diversity seem to differ based on who is asked. In the research survey, White healthcare executives cited the lack of access to diverse candidates, while racially and ethnically diverse respondents cited internal organizational resistance, including lack of commitment by top management and boards.(19) Regardless of the specific culprit, the answer may be as simple as meaningful mentorship.

The changes in healthcare have resulted in large integrated delivery systems that structurally and functionally parallel traditional, non-healthcare firms where mentorship and sponsorship are paramount to the career advancement of minorities. Over time, mentorship, more than any other diversity program, has been found to impact racial and ethnic minority representation among managers.(21) Eighty-four percent of respondents in the Witt/Kieffer report agreed that mentoring programs can aid in both enhancing the pool of leadership candidates and in developing leadership.(19)

Mentorship that is associated with racial and ethnic minorities plateauing in management should go beyond basic instruction. Rather, mentorship that includes developmental relationships is more likely to result in a rise to executive level, particularly for early-career racial and ethnic minorities. Developmental relationships involve more personal connection, include awareness of mentee race challenges, provide emotional support and enhance networks, and subsequently result in building confidence, credibility, and competence. As a prerequisite, mentors should gain an understanding of how minorities can advance in corporations.(22)

Other diversity initiatives play a complementary role in increasing racial and ethnic minority leadership presence in healthcare. It’s not surprising that a majority of the hospitals surveyed in the Institute for Diversity in Health Management’s 2015 report lacked governing board goals for diversity membership, plans to increase racial and ethnic executive presence, and executive compensation tied to diversity goals. Most respondents also lacked diversity goals in the performance expectations of their hiring managers and did not have programs in place that identified racial and ethnic minorities for promotion.(23) These goals all represent opportunities to gain ground and should be considered by organizations looking to improve minority recruitment and retention.

Witt/Kieffer also suggests that the development of leadership pipelines, a culture that supports diverse leadership, search firm cooperation, and building of relationships with diverse professional organizations are avenues to healthcare leadership diversity success.(19)

Improving racial and ethnic diversity among leadership in academic medical centers is multilayered. Pipeline programs and other initiatives that increase minority representation in U.S. medical schools and the physician workforce should certainly translate to a medical school faculty that is more racially and ethnically diverse. From there, programs and initiatives geared toward promoting more minority physicians toward associate professor and full professor ranks on par with the rates of White physicians should position more racial and ethnic minorities to compete for chair and dean roles.

References

1. Health Resources and Services Administration. The Rationale for Diversity in the Health Professions: A Review of the Evidence. U.S. Department of Health and Human Services, Bureau of Health Professions; Washington, DC: U.S. Government Printing Office; 2006.

2. Wakefield M. Improving the Health of the Nation: HRSA’s Mission to Achieve Health Equity. Public Health Rep. 2014;129 Suppl 2(Suppl 2):3–4. doi:10.1177/00333549141291S202

3. Alsan M, Garrick O, Graziani G. Does Diversity Matter for Health? Experimental Evidence from Oakland. NBER Working Paper No. 24787. National Bureau of Economic Research. June 2018.

4. Poole KG. Patient-Experience Data and Bias – What Ratings Don’t Tell Us. N Engl J Med. 2019;380:801–03.

5. Laveist TA and Nuru-Jeter A. Is Doctor-Patient Race Concordance Associated with Greater Satisfaction with Care? J Health Soc Behav. 2002 Sep;43(3):296–306.

6. LaVeist TA, Nuru-Jeter A, Jones KE. The Association of Doctor-Patient Race Concordance with Health Services Utilization. J Public Health Policy. 2003;24(3-4):312–23.

7. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Sex, Race, and Ethnic Diversity of U.S. Health Occupations (2011-2015). Rockville, Maryland; 2017.

8. Cantlupe J. The Rise (and Rise) of the Healthcare Administrator. AthenaInsight. Athena Health. Nov. 7, 2017. https://www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator

9. Johnson SR. Rise in Physician MBA Programs Creates Opportunities, Challenges for Business Schools. Modern Healthcare. Oct. 6, 2018. https://www.modernhealthcare.com/article/20181006/NEWS/181009968/rise-in-physician-mba-programs-creates-opportunities-challenges-for-business-schools

10. Kight SW. United States is on the Way to Becoming a Non-white Majority by 2045. Business Insider. May 1, 2019. https://www.businessinsider.com/america-non-white-majority-future-by-2045-2019-5

11. Institute for Diversity and Health Equity, Health Research & Education Trust. “Diversity and Disparities: A Benchmarking Study of U.S. Hospitals in 2015.” Institute for Diversity and Health Equity. 2016. https://ifdhe.aha.org/benchmarking-study-us-hospitals-surveys

12. Gaumer G and Coulam RF. Geographic Variation in Minority Participation in Hospital Management in the United States. Hosp Top. 2009;87(2):13–24. DOI: 10.3200/HTPS.87.2.13-24

13. Association of American Medical Colleges. Diversity in Medical Education: AAMC Facts & Figures 2016. Current Trends in Medical Education. https://www.aamcdiversityfactsandfigures2016.org/report-section/section-3

14. Palepu A, Carr PL, Friedman RH, Amos H, Ash AS, Moskowitz MA. Minority Faculty and Academic Rank in Medicine. JAMA. 1998 Sep 2;280(9):767–71.

15. Abelson JS, Symer MM, Yeo HL, Butler PD, Dolan PT, Moo TA, Watkins AC. Surgical Time Out: Our Counts Are Still Short on Racial Diversity in Academic Surgery. Am J Surg. 2018;215(4):542–548.

16. Yu PT, Parsa PV, Hassanein O, Rogers SO, Chang DC. Minorities Struggle to Advance in Academic Medicine: A 12-y Review of Diversity at the Highest Levels of America’s Teaching Institutions. J Surg Res. 2013 Jun 15;182(2):212_8. doi: 10.1016/j.jss.2012.06.049. Epub 2012 Jul 17.

17. Hunt V, Layton D, and Prince S. Why Diversity Matters. McKinsey & Company, Jan. 2015. https://www.mckinsey.com/business-functions/organization/our-insights/why-diversity-matters

18. Hunt V, Prince S, Dixon-Fyle S, and Yee L. Delivering Through Diversity. McKinsey & Company, Jan. 2018. https://www.mckinsey.com/business-functions/organization/our-insights/delivering-through-diversity

19. Closing the Gap in Healthcare Leadership Diversity: A Witt/Kieffer Study. Nov. 9, 2015. https://www.wittkieffer.com/webfoo/wp-content/uploads/Closing-the-Gap-in-Healthcare-Leadership-Diversity-Final.pdf

20. Exploring the Benefits of Leadership Diversity. B.E. Smith Team. 2018. https://www.besmith.com/trends-and-insights/articles/healthcare-benefits-leadership-diversity

21. Dobbin F and Kalev A. Why Diversity Programs Fail. Harvard Business Review. 2016:94(7):53-60.

22. Thomas DA. The Truth About Mentoring Minorities. Race Matters. Harvard Business Review. 2001 Apr;79(4):98–107, 168.

23. Institute for Diversity and Health Equity. Diversity and Disparities: A Benchmarking Study of U.S. Hospitals in 2015. Institute for Diversity and Health Equity, 2016. http://www.diversityconnection.org