Use financial in­cen­tives to re­duce racial and eth­nic dis­par­i­ties in health­care

Modern Healthcare - - COMMENT - By Dr. Risa Lav­izzo-Mourey

Thir­teen years ago, I co-au­thored an In­sti­tute of Medicine re­port doc­u­ment­ing that racial and eth­nic mi­nor­ity pa­tients rou­tinely re­ceive lower-qual­ity care than their white coun­ter­parts, re­gard­less of in­come or in­sur­ance sta­tus.

While the re­port, “Un­equal Treat­ment: Con­fronting Racial and Eth­nic Dis­par­i­ties in Health Care,” re­ceived a lot of at­ten­tion in 2002, it is sadly still rel­e­vant to­day, given the per­sis­tence of the dis­par­i­ties it doc­u­ments.

As the Agency for Health­care Re­search and Qual­ity re­cently pointed out, even though we’re pro­gress­ing on im­prov­ing health­care qual­ity, we’re not so hot on im­prov­ing eq­uity. That’s not to say there haven’t been ef­forts to nar­row the di­vide. In 2010, the Af­ford­able Care Act au­thors specif­i­cally in­cluded pro­vi­sions to re­duce health­care dis­par­i­ties and in­crease cov­er­age op­tions for vul­ner­a­ble pop­u­la­tions. And at the Robert Wood John­son Foundation, elim­i­nat­ing health­care dis­par­i­ties is cen­tral to our vi­sion of build­ing a na­tion­wide cul­ture of health, where all Amer­i­cans have the op­por­tu­nity to live their health­i­est life pos­si­ble.

And we can point to real progress cre­at­ing the resources and knowl­edge base to ad­dress dis­par­i­ties. Through pro­grams such as Find­ing An­swers: Dis­par­i­ties Re­search for Change—a decade-long ef­fort funded by the foundation to seek and eval­u­ate strate­gies for elim­i­nat­ing dis­par­i­ties—we now know what does and doesn’t work.

Here’s what doesn’t work: You can’t get a han­dle on the ef­fec­tive­ness of qual­ity-im­prove­ment ac­tiv­i­ties aimed at im­prov­ing eq­uity if you don’t track care by pa­tient race and eth­nic­ity.

All too of­ten, th­ese ini­tia­tives are fo­cused solely on im­prov­ing over­all health, and ig­nore the crit­i­cal need to close the gap be­tween white and mi­nor­ity pa­tients.

Here’s what works: link­ing qual­ity and eq­uity. It’s im­por­tant to note the con­nec­tion be­tween the two, be­cause equal ac­cess can still re­sult in un­equal care. As Find­ing An­swers has shown, eq­uity is a cross-cut­ting com­po­nent of qual­ity. Over the past decade, par­tic­i­pat­ing clin­ics and hos­pi­tals have iden­ti­fied steps providers can take to link qual­ity and eq­uity, from col­lect­ing ba­sic pa­tient data to mea­sure dis­par­i­ties to im­ple­ment­ing cul­tur­ally ap­pro­pri­ate ap­proaches to pa­tient care. Find­ing An­swers has in­cluded this and other in­for­ma­tion in its Roadmap to Re­duce Dis­par­i­ties, an ev­i­dence-based frame­work that health­care or­ga­ni­za­tions, tech­ni­cal-as­sis­tance providers and pol­i­cy­mak­ers can fol­low to ad­dress dis­par­i­ties.

De­spite the ac­knowl­edge­ment and data show­ing that dis­par­i­ties ex­ist, many health­care ex­ec­u­tives con­tinue to falsely as­sume that dis­par­i­ties do not ex­ist at their in­sti­tu­tions, and there­fore, they are not ac­tively work­ing to elim­i­nate them. One study found that, while 88% of physi­cians be­lieve that racial and eth­nic dis­par­i­ties in di­a­betes care ex­isted, only 40% be­lieved such dis­par­i­ties ex­isted in their own prac­tices.

If providers nar­rowed their ap­proach and ex­am­ined per­for­mance data clas­si­fied by race, eth­nic­ity and even lan­guage, they would bet­ter un­der­stand the type and ex­trem­ity of dis­par­i­ties within their prac­tices, and could ap­pro­pri­ately and ac­tively ad­dress them. Sim­ply put, providers can cor­rectly iden­tify dis­par­i­ties by first un­der­stand­ing how they per­formed on a given qual­ity mea­sure for each racial group, and then com­par­ing their per­for­mance in one group against how they fared with an­other.

That’s why we need to ex­plore financial in­cen­tives as a tool to help the sys­tem take that step and ad­dress dis­par­i­ties. As we move for­ward and pre­pare for new re­im­burse­ment sys­tems, em­pha­siz­ing value of care over vol­ume, many em­ploy­ers and in­sur­ers are pur­su­ing providers who are ded­i­cated to pro­mot­ing eq­uity in their net­works. But some­times it’s tricky to con­nect all the dots.

Start­ing this fall, the Find­ing An­swers team is tran­si­tion­ing its work to a new pro­gram fo­cused on re­duc­ing dis­par­i­ties through pay­ment and de­liv­ery-sys­tem re­forms. This work will ex­plore whether and how pay­ment sys­tem changes might make it eas­ier for providers to make elim­i­nat­ing dis­par­i­ties a pri­or­ity.

We’re hope­ful that by mak­ing a busi­ness case for eq­uity, and rolling it into pay­ment, providers will be mo­ti­vated to check for dis­par­i­ties in their care and en­gage in qual­ity-im­prove­ment ef­forts to re­duce them.

At­tack­ing dis­par­i­ties from ev­ery an­gle—in­clud­ing the pock­et­book—is the only way we’ll en­sure that race and eth­nic­ity do not dic­tate the care pa­tients re­ceive. It’s a cru­cial part of work­ing to­gether to build a cul­ture of health that en­ables all in our di­verse so­ci­ety to lead health­ier lives, now and for gen­er­a­tions to come.

In­ter­ested in submitting a Guest Ex­pert op-ed?

View guide­lines at mod­ern­health­care.com/op-ed. Send drafts to As­sis­tant Man­ag­ing Editor David May at dmay@mod­ern­health­care.com.

Dr. Risa Lav­iz­zoMourey is pres­i­dent and CEO of the Robert Wood John­son Foundation.

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