Reframing a National Dialogue About Health Care Disparities
Over the past 100 years, the Commonwealth Fund has highlighted inequities in health care quality and outcomes — between men and women, rural and urban, young and old, rich and poor, and minority and white populations. The Fund’s strategy for addressing them, described in this essay, has been to invest in understanding their root causes and supporting innovative efforts to close the gaps.
I took part in this work when I led the Fund’s Program on Quality of Care for Underserved Populations from 2002 to 2009. One area of focus was examining health care disparities for racial and ethnic minorities, who often have worse health care quality and poorer health outcomes than other Americans, including lower life expectancy, higher infant mortality rates, and higher death rates from diabetes, heart disease, and cancer.
For much of the 20th century, health outcomes for minority patients were thought to be a function of genetic differences and/or related to the effects of poverty — but fundamentally because of factors outside of the health care system. Then two important studies changed that thinking: a New England Journal of Medicine study published in 1999 showed that, when asked to view videotaped interviews with black, white, male, and female actors posing as patients complaining about chest pain, cardiologists were less likely to send black women for cardiac catheterization than they were to recommend the procedure for others with the same clinical presentation and histories. It was incontrovertible evidence that physicians’ treatment recommendations may be influenced by factors other than patients’ clinical presentations.
The second was the 2001 Crossing the Quality Chasm report from the Institute of Medicine, which offered compelling evidence that the U.S. health care system does not provide high-quality care at all times and to all people. This raised the question of how health care quality varies for patients from different racial and ethnic groups.
The Fund’s Program on Quality of Care for Underserved Populations built on this foundational work. Most crucially, we supported research that helped reframe the discussion of “minority health” into a discussion of disparity. Language matters, and this term made it clear that the poor health outcomes among Americans of color were because of a gap in health care quality — one that could be improved. It also made clear to health system leaders that their efforts to improve their overall quality performance would not succeed unless they focused on patients at particular risk, including minority Americans.
We made a series of grants to several investigators, including Romana Hasnain-Wynia (here and here), now chief research officer at Denver Health, to make it easier for health systems to evaluate their performance by collecting data on patients’ race and ethnicity that could be used to stratify clinical quality measures. Soon after, research funded by the Robert Wood Johnson Foundation and led by George Washington University’s Sara Rosenbaum demonstrated that health systems had the ethical and legal right to collect data on patients’ race and ethnicity. Taken together, there was a strong push to understand disparities in health care quality, and the extent of those disparities in national and local contexts.
As the data on the quality of care among racial and ethnic minorities within health systems began to roll in, what we found — and didn’t find — was surprising. In some cases, health systems found no or only minor differences based on race and ethnicity; there were also places where minorities seemed to receive higher-quality care than whites. While the Agency for Healthcare Research and Quality’s annual National Healthcare Quality and National Healthcare Disparities reports consistently found evidence of widespread racial and ethnic disparities, they were not always apparent within individual health systems.
As we had more data, we started to see that health care, like housing, is very segregated, with white Americans and minority Americans often seeking care in different institutions. An important study by Hasnain-Wynia concluded that minority patients, in aggregate, often received worse-quality care because they went to lower-performing institutions. (Provider bias was also likely an issue, but clinical quality measures were not refined enough to capture it.)
The Commonwealth Fund gave a grant to James Reschovsky, now at Mathematica Policy Research, to explore the differences between institutions serving mostly white and mostly minority patients, and perhaps not surprisingly it came down to money: minority-serving institutions had higher proportions of patients covered by Medicaid than institutions serving fewer minority patients. His modeling suggested that if Medicaid paid providers at the same rates as Medicare, many racial and ethnic disparities in health care quality could be eliminated.
Further evidence that improvement was possible came from a 2006 Commonwealth Fund survey, which found that when blacks and Hispanics had stable insurance and access to a high-performing primary care medical home, many disparities in terms of access to and quality of care disappeared.
Since then, the Fund has supported efforts to strengthen safety-net systems, including the community health centers and public clinics where many minority Americans get their care. More recent work shepherded by Pamela Riley, M.D., vice president for Delivery System Reform, is seeking to promote state-of-the-art primary care for low-income patients, including by supporting efforts to address the social factors that fuel poor health.
After 100 years, the goal of this work remains the same: to reduce variation in treatment and care outcomes in the recognition that a high-performing health system is one that delivers the best care to all.
Please visit centennial.commonwealthfund.org