Background

A 1992 joint study by the American College of Healthcare Executives (ACHE), an international society of healthcare executives and the National Association of Health Services Executives (NAHSE), the association of black healthcare executives, compared the career attainments of their members. The study documented that though blacks and whites had similar educational backgrounds and years of experience in the field, blacks held fewer top management positions, less often worked in hospitals, earned 13 percent less and were less satisfied in their jobs. A set of recommendations was put forward that urged specific actions be taken by leaders in the field, by employers of black healthcare executives and by blacks themselves. It concluded that another study should be conducted in 3 to 5 years to determine whether career outcomes improved for black healthcare executives compared to their white counterparts.

In 1997, ACHE and NAHSE pursued this objective and conducted another national survey of their members. The study was enlarged to include Hispanic and Asian healthcare executives as well. For this reason, two other organizations were asked to collaborate: the Association of Hispanic Healthcare Executives (AHHE) and the Institute for Diversity in Health Management.

Methods

The population of black healthcare executives included all NAHSE members as well as members of ACHE who identified themselves as black. The population of white healthcare executives consisted of members of ACHE. AHHE provided the list of Hispanic healthcare executives which was supplemented with ACHE Hispanics. Finally, Asians, who do not have a national membership organization, were identified from the membership files of the ACHE.

This 1997 follow-up study consists of two efforts. The first termed the cross-sectional study, parallels the 1992 study. As in 1992, a detailed questionnaire was administered to determine not only career outcomes, but also factors that might account for differences observed as well as attitudes and policies that might affect careers in the future. Respondents by race/ethnicity were 410 blacks (54 percent response rate of which 380 were analyzed); 408 whites (51 percent response rate of which 386 were analyzed); 264 Hispanics (40 percent response rate of which 240 were analyzed); and 124 Asians (53 percent response rate of which 115 were analyzed). Responses were analyzed if they were provided by employed healthcare executives who gave their gender. (Table 1)

The second effort, termed the follow-up study, resurveyed the respondents to the 1992 survey. Of the 328 black respondents to the 1992 survey, 106 or 32 percent were located and responded to the follow-up study. Of the 524 white respondents to the 1992 survey, 289 or 55 percent responded to the follow-up study in 1997. Data for both the cross-sectional and follow-up studies report results for women and men separately since the groups have different proportions of females and males. This allows us to focus on race/ethnicity controlling for gender.

Major Findings: Cross-sectional Study

In 1992, about 45 percent of black and white women were general managers. Today, white women retain their involvement in general management but black women declined in this area to 32 percent. Nearly as many Hispanic women (44 percent) as whites are general managers while only about a third of the Asian women are general managers. In contrast to these findings for women, almost three out of four white men were in general management in 1992 compared to about half of the black men in this area. In 1997, these differences between black and white men are narrowing. Today, 42 percent of blacks, 56 percent of whites, 43 percent of Hispanics and 51 percent of Asian men are general managers. (Table 4)

 In 1992, blacks were less often employed in hospitals than whites; this continues to be true in 1997. Hispanics and Asians, like the black healthcare executives, are also less often employed in hospitals than whites. (Table 5)

 In 1992, black women served as mentors about as often as white women; but more black men took on this role than white men. Both patterns continue to be true in 1997.While about the same proportion of all women today are mentors, Hispanic and Asian men fall between the high proportion of black men and the low proportion of white men serving as mentors. (Table 6)

In 1992, black women earned 8 percent less than white women on average. Today, black women earn 17 percent less than white women, Hispanic women earn 19 percent less and Asian women 20 percent less than white women. In 1992, black men earned 18 percent less than whites. Today, the gap is narrowing, blacks earn on average, 12 percent less than whites, Hispanic men earn 11 percent less and Asian men earn 4 percent less. (Table 7)

Modeling the expected salaries of the race/ethnic groups suggests that if blacks and Hispanics obtain the same amount of education and years of experience as whites, they will not be as well remunerated as whites in senior level positions. (Table 9)

 In 1992, and again in 1997, black women express less satisfaction than whites relative to pay and fringe benefits, security, sanctions and treatment received when they made a mistake, respect from supervisors and autonomy. Hispanic women’s satisfaction generally fell between the level of blacks and whites. Asian women expressed the highest level of satisfaction in regard to security and autonomy but were least satisfied among the groups with their pay and fringe benefits. (Table 10)

 In 1992, black and white males did not differ in regard to satisfaction with pay and fringe benefits nor with regard to supervisors’ respect. But by 1997, black men, despite the narrowing of their pay differential, express less satisfaction with these features of their job compared to whites. Hispanic and Asian men held opinions about their pay between the extremes set by the blacks and whites. However, Hispanic and Asian men resembled white men who were predominantly satisfied with the respect they received from their supervisors. (Table 10)

Education and Early Career Experiences. Black men, but not black women, are less likely to have a graduate degree today than white, Asian or Hispanic men. With the exception of Hispanic women, over half of all the groups took their graduate degrees in healthcare management. (Table 13)

Hispanics are more likely to launch their careers in public health agencies; in general, minorities are more likely to launch their careers in governmental organizations. As was true in 1992, minorities are less likely than whites to begin their careers in freestanding hospitals. (Table 15)

As was true in 1992, more blacks continue to take part-time jobs or less desirable jobs than whites because of financial need and lack of opportunity. In 1997, more blacks than Hispanics and Asians held such positions. (Table 17)

In 1992, white women said they were less willing to relocate to obtain a better position than blacks; today there are no significant differences between any of the comparison groups—blacks, whites, Asians or Hispanics.

About 60 percent of blacks, 35 percent of Asians, 30 percent of Hispanics and 10 percent of whites stated they have been negatively affected by racial/ethnic discrimination in their careers. Blacks expressed the least satisfaction with the progress they had made toward meeting their overall career goals. (Table 18)

Current Organization. Considering their current employer, the largest proportion of respondents was recruited as department heads. But the current position shows that white women are about twice as likely to hold CEO or COO positions as minority women. (Table 19) A similar disparity is evident comparing Asian and white men while other minority men hold CEO or COO positions about three quarters as often as white men.

In 1992, more than half of the black men compared to a third of the white men reported their organizations held recruiting events targeted toward minorities. Today, about a third of both groups report such activity. (Women reported no significant differences in the two years.) In 1997, more minorities reported that their organizations set targets for hiring minorities. A larger proportion of organizations employing Hispanics (one-third) and Asians (one-fourth) than those employing blacks or whites (one-fifth) reward fluency in Spanish. (Table 23)

White women work longer hours than blacks or Asians at the office; black women work longer hours on their professional activities at home. Hispanic men work fewer hours at the office and more hours outside the office. (Table 24)

In 1992, white women and men were more involved in recruiting physicians than blacks. Today this pattern persists and, in addition, white women are more involved than black women in recruiting nurses and administrators. (Table 25)

In 1992, whites reported more non-work socializing with both black and white managers at lunch and by participating in sports. These differences have disappeared except that black women again socialize less with members of other race/ethnic groups at lunch. (Table 26)

Blacks and whites are at opposite poles in regard to various features of their organizations’ fairness such as salary, promotions and recognition. Blacks feel their organizations do not treat them as fairly as whites, that minorities need to be more qualified to obtain positions and that race relations need to be improved. Hispanic and Asians fell midway between blacks and whites in these views. (Table 28)

About 40 percent of blacks and less than 5 percent of whites experienced racial/ethnic discriminatory acts in the past five years—acts like not being hired, promoted, fairly compensated or evaluated with appropriate standards. Hispanic and Asians fell between responses expressed by whites and blacks. (Table 29)

Career Expectations. More blacks reported they would likely leave their current employers in the coming year than whites, Hispanics or Asians. (Table 30)

About the same proportion of all respondents plan to work in various healthcare settings in the next half decade; also about the same proportion plan to become CEOs in 5, 10 and 15 years. (Tables 31, 32)

General attitudes and policies promoting equity. Respondents feel subordinates and supervisors give about the same level of support regardless of the manager’s race/ethnicity. But minorities say that their evaluations are less thorough or careful than those given to whites.

In evaluating their colleagues, minorities feel that whites fail to share growth and career related information with them. More minorities than whites stated that the quality of all their collegial interactions —with both other minorities and whites could be improved.

Despite the expressed need for improved relationships, about 90 percent of each race/ethnic group would recommend the field to a young person today. (Table 34)

Minorities claim in written-in in responses that they are treated unfairly due to structural factors in the system—embedded racism, lack of organizational commitment to affirmative action, a paucity of mentors and the influence of the "good old boys" clique. Hispanics and Asians also attribute career inequities to language and cultural differences.(Table 35)

A majority of all race/ethnic groups thought that managers should take public positions on equal employment opportunities and affirmative action. But though nearly 60 percent of whites agreed with this role, over a fifth disagreed. In 1992 and 1997, 80 percent of black managers agreed. But agreement by whites declined in the past 5 years by about 12 percent among the women and by 16 percent among the men. (Table 36)

Government, in the view of two thirds of the blacks, half of the Hispanics and just over a third of Asians should create incentives for the healthcare industry to engage in equal employment practices. Only 11 percent of whites agreed—and 70 percent of them disagreed—a repeated finding from the 1992 study. (Table 36).

Major Findings: Follow-up Study

After 5 years, 395 of the 852 original respondents to the 1992 survey (46 percent) provided information about their career attainments in 1997. Specifically, 32 percent of the 328 blacks studied in 1992 and 55 percent of the 524 whites studied in 1992 were located and responded to the follow-up survey. (Table 38) Comparing the proportion of respondents who attained senior level positions showed that the gap had closed; whereas blacks held about 60 percent as many senior positions as whites in 1992, by 1997 equal proportions of men and women held senior level positions among blacks and whites. (Table 39)

In 1992, blacks males were disproportionately working for non-providers such as consulting firms, educational organizations and associations. By 1997, this difference is no longer evident. (Table 40)

While in 1992, black women earned 16 percent less than white women, in 1997, black women continue to earn 17 percent less than white women. The gap is closing however, between black and white men. In 1992, black men earned 10 percent less than white men; in 1997, black men earn 7 percent less. (Table 41)

Compared to whites, black women in 1992 were less satisfied with their pay and fringe benefits, sanctions received when they made a mistake and respect they received from their supervisors. These sources of dissatisfaction persist today. However, black women today are nearly as satisfied as white women with their autonomy. Among black men, in 1992, the major difference with whites, was blacks’ sense of lesser respect given by their supervisors. In 1997, their source of dissatisfaction has shifted to the area of pay and fringe benefits—even though as shown above, their average gap in pay has diminished. (Table 42)

The comparison of aspirations respondents reported in 1992 with their actual career accomplishments five years later show that the proportion that met or exceeded their goals was not significantly different when comparing black and white women. Among men, fewer blacks met their positional aspirations.

Finally, whereas in 1992 more white women than black women aspired to CEO positions; today, similar proportions of blacks and whites seek senior level positions in the year 2002. Among men, fewer in both black and white groups desire senior level positions in the future. (Table 44)

Discussion and Conclusion

The concluding section focuses on the possible interrelationships of some of the main career outcomes. This conclusion focuses primarily on the cross-sectional study where we were most interested to determine if the pattern of lower career attainment among blacks compared to higher career attainment of whites was as true in 1997 and was the case in 1992.

We learned that several key findings observed in 1992 have not improved. For example, a higher proportion of white women now work as senior level executives than black women. Corresponding to this is the finding that the gap between white and black women’s salary increased and that as discovered earlier, a lower proportion of blacks than whites work in hospitals. Not surprisingly, black women remain less satisfied than white women with several areas of their jobs—pay, security, sanctions given when errors are made, supervisor’s respect and autonomy.

The pattern observed for women is not, however, repeated for men. Here we saw greater similarity between the proportion of blacks and whites who achieved high level management positions and correspondingly, a lessening of the salary gap between black and white men as well. Somewhat surprising was the fact that black men’s satisfaction with their pay and fringe benefits actually declined in comparing the 1992 and the 1997 study participants. It will be recalled that in the cross-sectional study, these are different individuals who nevertheless, are believed to represent a cross section of each race/ethnic group.

The possible explanations for the declining satisfaction among black men relative to whites in pay and fringe benefits are (1) they are responding to the continued existence of a 12 percent gap that persists in black and white men’s pay despite having narrowed the positional gap; (2) they are reacting to the accrued inequity experienced by members of their race, and, like the experiences observed in newly liberated states, are giving vent to their pent up frustrations. In any case, the "bottom line" results appear overall positive for men in this five year follow-up study.

This paragraph and the next focus on the main conclusions of the follow-up study. What did the follow-up study show as we tracked the careers of the original 1992 respondents? These individuals are followed more to learn about evolving career paths than to provide a national picture of career differences that currently exist. We showed that comparing positions attained, few differences are now evident between both black and white men and black and white women. Moreover, though fewer blacks than whites appear to be employed in hospitals, the differences are not statistically significant. Further, comparing salaries, the gap between black and white men has declined from 10 percent in 1992 to 7 percent today. Unfortunately, the gap between black and white women’s salaries has persisted at about 17 percent.

As was evident in the cross-sectional study, black women and men in the follow-up study are significantly less satisfied than their white counterparts with their pay and fringe benefits. The explanation for the growing gap may be the same as those reasons postulated above.

The report concludes by considering the 8 recommendations that accompanied the 1992 report which were designed to reduce the inequities between blacks and whites uncovered at that time. Specifically, Recommendation 1 urged "executives... to recruit and promote black managers, with requisite preparation, at all levels." Are the experiences reported by this 1997 cohort better than the 1992 cohort relative to recruitment and promotion?

If we consider first position (Table 15), we can see that among women, blacks continue to be more often recruited into sector management, e.g., ambulatory care, associations, etc. But among men, there has been a leveling out—whites and blacks are about equally likely to begin their careers in general management. On the other hand, whites continue to be disproportionately recruited to hospital positions and to organizations under not-for-profit church sponsorship whereas blacks less often take their first position in a hospital and more often begin their careers in governmental organizations.

Table 20 suggests that compared to white women, black women are less often promoted from senior vice presidencies to CEO. However, black and white males’ promotions appear quite similar. Table 21 shows that blacks and whites were about equally optimistic about the likelihood of their being promoted in the coming year. We conclude that Recommendation 1 has apparently benefited black men but not black women.

Recommendation 2 suggested that the first healthcare management position is related to the current position attained and that blacks and whites should seek organizations similar to those in which they hope to build their careers. This was not ascertained in this study.

Recommendation 3 called for blacks and their employers to work together to recruit for various positions. As shown in Table 25, blacks continue to be less involved in recruiting physicians than whites and the disparity has now extended to white’s being more involved than blacks in recruiting nurses and administrators as well. The recommendation has not been effected.

Recommendation 4 indicated that networking and informal collegial interaction appear to enhance career attainments. We showed that while black men socialize with minority and white managers as much as whites do today, black women continue to socialize less with them at lunch. We conclude that Recommendation 4 has apparently benefited black men but not black women.

Recommendation 5 called for professional organizations of healthcare executives to develop policies that encourage their members to endorse affirmative action and equal opportunities. In May, 1995, the ACHE strengthened and reissued its policy statement on enhancing minority opportunities in healthcare management. However, as evident in Table 36, today, the proportion of black executives endorsing management’s responsibility to take public positions on these issues remained nearly the same (about 80 percent) but the proportion of whites actually declined 20 percent since the 1992 survey. Whites in the study are probably reflecting a more general backlash against preferential treatment for any group. We conclude that while the processes of Recommendation 5 were effected, the outcomes have actually suffered a reversal.

Recommendation 6 asked that more efforts be made to increase access to financial assistance for black students in health services administration programs. This study did not address that issue. We know that the Institute for Diversity in Health Management has worked for such assistance since its founding in 1994 by the American Hospital Association, ACHE and NAHSE as has the ACHE in the aforementioned policy statement.

Recommendation 7 suggested the results of the study should be disseminated widely—especially to executive search consultants. It was thought that their daily experience with hiring and promotion decisions make them a valuable resource to suggest techniques that would enhance the career opportunities of black healthcare executives. In fact, a special presentation was made to executive search firm representatives in October, 1993. In addition, subsequent presentations have been made by the Institute for Diversity to search firm representatives.

Recommendation 8, to conduct another study in 3 to 5 years is represented by this report.

Although only some of the objectives of the 1992 study were realized (or partially realized) in the past half decade, it might be worthwhile to conclude by emphasizing one major challenge that emerged from this research. In 1997, contrary to the minorities’ views, fewer than half—44 percent—of whites agreed that the quality of relationships between minority and white managers could be improved. This is a scant improvement from the findings reported 5 years ago. Clearly, before a problem perceived by over 80 percent of blacks and about two thirds of Hispanics and Asians can be solved, it must acknowledged. It is hoped that this second report has provided additional evidence about the persistent and pervasive inequities in the career attainments of minority healthcare managers.