in health care access and quality of care have been well documented by
The Commonwealth Fund and others. The goals of The Commonwealth Fund's
Program on Health Care Disparities are to improve the overall quality
of health care delivered to low-income and minority Americans, and to
eliminate racial and ethnic health disparities. The program builds on
efforts to improve quality of care overall in the United States,
focusing on safety-net hospitals and ambulatory care providers serving
large numbers of low-income and minority patients. The strategies it
- identifying opportunities for improving performance of safety-net providers;
- enhancing the capacity of safety-net providers to improve performance; and
- fostering incentives and policies that promote better performance of safety-net providers.
The Program on Health Care Disparities is led by Assistant Vice President Anne C. Beal, M.D., M.P.H.
Commonwealth Fund work focused on reducing health disparities through
improved data collection and reporting found that low-quality providers
serve disproportionate numbers of minorities. Fund research also helped
define and develop standards for cultural competence and initiated
clinical interventions targeted at safety-net providers. The program
now aims to improve the performance of minority serving safety-net
hospitals and ambulatory care providers in order to reduce disparities
in access to high quality care.
While there is broad consensus regarding the existence of racial and
ethnic disparities in health care, there is less agreement about the
root causes. Using data from the 2004–05 Community Tracking Study
Physician Survey, James D. Reschovsky, Ph.D., and Ann S. O'Malley,
M.D., M.P.H., senior health researchers at the Center for Studying
Health System Change, examined how the socioeconomic and insurance
composition of a provider's patient base contributes to racial
disparities. They found that primary care physicians who treat a
disproportionate share of black and Latino patients provide more
charity care, see more patients, depend more heavily on low-paying
Medicaid, and earn lower incomes than physicians with largely white
patient populations. In "Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?" (Health Affairs
Web Exclusive, Apr. 22, 2008), the they concluded that such payment
constraints help explain why physicians who treat large numbers of
minority patients report more problems delivering high-quality care
than other physicians.
Quality of Care in Hospitals.
Research has shown that minority patients tend to see primary care
physicians who have less clinical training, see specialists whose
patients have poorer clinical outcomes, and seek care at
lower-performing hospitals than do white patients. However, a Commonwealth Fund-supported study led by Darrell J. Gaskin, Ph.D., of the University of Maryland and published in Health Affairs
finds that when minority and white patients seek care at the same
hospital, they receive the same standard of care. These results
highlight a fundamental rule: minority patients receive the best care
when they are treated in hospitals that deliver the highest quality
care. Thus, eliminating disparities may require getting minority
patients to receive care in higher performing, rather than
Medical Homes Address Disparities in Access. Findings from "Closing the Divide How Medical Homes Promote Equity in Health Care"
based on findings from The Commonwealth Fund 2006 Health Care Quality,
showed that racial and ethnic disparities are not immutable. Indeed,
the survey found that disparities in access to and quality of care
largely disappear when adults have a medical home, insurance coverage,
and access to high-quality services and systems of care. systems, in
the form of patient reminders, also improve the quality of care for
vulnerable patients by promoting higher rates of routine preventive
screening. This report was recently cited by two experts during June
10, 2008 testimony to House Ways and Means Health Subcommittee, and has
also been cited in draft legislation.
The Program on Health Care Disparities is interested in funding the following types of projects:
of the current level of performance among minority-serving safety-net
providers, and factors associated with high performance in terms of
quality of case, patient experiences, and efficiency.
of innovative models and practices that lead to high performance among
minority-serving safety-net hospitals and ambulatory care providers.
of the impact of current payment policies, particularly through
Medicaid and Medicare, on safety-net provider performance.
- Evaluations of health reform and its impact on safety-net provider performance.
example, to improve performance, the program is supporting Alicia
Fernandez, M.D., and Hilary Seligman, M.D., M.S., of the University of
California, in their evaluation of a Fund-supported survey
instrument—the Patient Assessments of Cultural Competency. This project
will expand the scope of a study of diabetes patients at large
safety-net hospitals in San Francisco and Chicago. The investigators
aim to determine how these patients' diabetes outcomes are affected by
patient care experiences and cultural competency in health care
delivery. The Russell Sage Foundation will cofund the project.
another project, Jordan Peugh, M.A., of Harris Interactive will conduct
a national survey of CEOs at 1,078 federally qualified health care
centers—important providers of care to low-income, uninsured, and
minority patient populations—to examine the extent to which their
organizations possess the systems and capacity needed to achieve high
performance. The survey will focus on medical home structures,
engagement in quality improvement activities, and workforce capacity.
To investigate the association between clinical performance and
organizational measures of high performance, the survey data will be
linked to the Uniform Data System used by the Bureau of Primary Health
Linda Cummings, Ph.D., and colleagues from The National
Public Health and Hospital Institute, will examine emergency department
(ED) throughput in public hospitals—that is, how efficiently patients
can be seen, cared for, and appropriately discharged. The team will
identify safety-net hospitals that have eased ED overcrowding and
improved patient flow. After analyzing the strategies used by the
high-performers, they will develop an educational program for 15 public
safety-net hospitals that are working to improve ED throughput. Working
collaboratively, these facilities will then develop initiatives to
increase their efficiency and ability to provide high-quality,
efficient emergency care.
Another study, led by Sara Singer,
M.B.A., Ph.D., and Nancy Morgan Kane, M.B.A., D.B.A., of Harvard
College will identify governance practices and organizational
characteristics (such as ownership or affiliation with a Medicaid
managed care plan or primary care clinics) of top safety-net hospitals.
They will identify practices that lower-performing hospitals could
adopt to raise their financial performance and improve quality of care.
To do this, project staff will analyze audited financial statements and
standardized quality measures, conduct site visits and interviews, and
prepare six case studies that feature the practices of high-performing
Romana Hasnain-Wynia, Ph.D., and colleagues
from the Health Research and Educational Trust, will conduct the first
national study of quality in safety-net hospitals, using national data
provided by the Hospital Quality Alliance and the American Hospital
Association. The project investigators will focus on the treatment
provided to patients admitted with myocardial infarction, congestive
heart failure, and community-acquired pneumonia. As part of the study,
the project team will survey leaders of safety-net hospitals to
determine the extent to which their institutions possess organizational
systems and capacity, such as electronic health record systems, needed
to engage in quality improvement activities. Based on these findings,
the investigators will recommend steps that safety-net hospitals can
take to achieve higher performance.
Federally funded community
health centers (CHCs) are an integral part of the health care safety
net for disadvantaged communities. Deborah Gurewich, Ph.D., and Donald
S. Shepard, Ph.D., of Brandeis University, will determine the extent to
which health centers in three states with large low-income, minority
populations (California, Massachusetts, and Texas) provide
cost-effective care, identify health centers that provide high-quality
care at reasonable costs, and pinpoint the factors that contribute to
the success of these high-performing community health centers. The
Texas Association of Community Health Centers will provide cofunding.
To apply for a grant from the Program on Health Care Disparities, visit the Applicant and Grantee Resources page.