By Anne Beal, M.D., M.P.H.
Recent Commonwealth Fund research has sought to answer a key question: do racial and ethnic disparities in health care quality occur because minority Americans are treated differently by their providers, or because minorities receive care in lower-quality facilities? In other words, are disparities the result of who you are or where you seek care?
Many studies have pointed to the roles of bias, miscommunication, and lack of trust in creating health disparities. Racial and Ethnic Disparities in Health Care: A Chartbook, prepared by researchers at the George Washington University and published last month by The Commonwealth Fund, presents compelling evidence that health care disparities in hospitals are often due to the quality of the facilities minorities visit. The chartbook also provides a snapshot of minority health and outlines quality improvement techniques for reducing disparities.
As the chartbook makes clear, minorities fare worse than white Americans on almost every measure of health status and outcomes. For example, whites born in 2003 could expect to live to 78, while life expectancy for a black person at birth was 5.3 years shorter. The infant mortality rate for non-Hispanic blacks that year was 2.5 times greater than for whites. Blacks are also more likely to have diabetes, heart disease, and certain cancers than whites. Health status is affected by several factors including stress, income, and education levels.
What's more, minorities are much more likely than whites to be uninsured and to face barriers to accessing health care. Black, Hispanic, and Asian American adults are less likely to have a regular source of care than white adults. For Hispanics in particular, limited access to care means skipping care. In 2006, nearly half of Hispanics reported they did not always get care when needed, compared with 43 percent of blacks and 41 percent of whites. But emerging evidence shows that even minority Americans who have insurance are more likely to receive care from lower-quality providers.
A Commonwealth Fund–supported study published in Health Affairs, led by Darrell J. Gaskin, Ph.D., of the University of Maryland, found that racial and ethnic health disparities exist across hospitals, rather than within individual facilities. According to the study, when minority and white patients went to the same hospitals, they received the same standard of care. However, minorities were more likely to go to hospitals that provided lower-quality care.
Another study by Elizabeth Howell, M.D., and other researchers at Mount Sinai School of Medicine found similar results. It showed black women were more likely to have low birth weight babies, a condition linked to infant mortality. Black low birth weight babies were also more likely than their white counterparts to be born in hospitals with higher neonatal death rates, thus leading to a disparity in infant mortality. The authors concluded that improving quality in these hospitals could significantly reduce this disparity.
Likewise, an investigation led by Romana Hasnain-Wynia, Ph.D., now at Northwestern University, used patient-level quality measures to assess racial and ethnic disparities. The researchers found minority patients receive lower-quality care, and that lower-performing hospitals tend to serve a greater proportion of minority patients. The authors concluded that where patients receive care is a major driver of disparities.
Other Fund research suggests that a centerpiece of patient-centered care—the medical home—has the potential to reduce or eliminate disparities in terms of access to and quality of care. Findings from the Commonwealth Fund 2006 Health Care Quality Survey demonstrated that patients who had stable health insurance and a medical home—defined as a primary care setting that provides timely, coordinated care and off-hours access—had better access to care, better quality of care, and better health outcomes than patients without such medical homes. The authors of the survey report, Closing the Divide, found that minorities who had access to a medical home were just as likely as whites in medical homes to have access to needed care, receive routine preventive screenings, and manage their chronic conditions.
It is possible to transform safety net hospitals and clinics into high-performing institutions. Consider the case of Denver Health, a comprehensive, integrated medical system and Colorado's largest health care safety net provider. According to a recent case study, Denver Health has succeeded at providing coordinated care to the community, promoting a culture of continuous quality improvement, adopting new technology and incorporating it into everyday practice, taking risks and making mid-course corrections, and providing leadership and support—and accepting accountability—both at the top and throughout the organization.
Addressing disparities by improving the quality of care delivered by providers who care for minority patients is a new way to address a longstanding problem—one that could prompt policymakers and health professionals to forge innovative solutions. In particular, establishing medical homes and rewarding high-performing health care organizations—and ensuring everyone has access to affordable health coverage—could benefit all Americans while significantly improving care for minority populations.
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March 2008Written with the assistance of Christine Haran and Martha Hostetter