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Equity Measures and Systems Reform as Tools for Reducing Racial and Ethnic Disparities in Health Care

Executive Summary

While Medicaid and Medicare have expanded access to health care for poor and minority Americans, these programs have yet to fully address the relatively low quality of care that many receive. Even when minority Americans have similar access to care as others do—utilizing the same health insurance or institutions of care or managed care plans—they often receive significantly fewer services and poorer quality care.

Some of the disparities in health care result from individual provider and patient behavior: prejudice, stereotyping, poor communication, or uncertainty in decision-making. Others are attributable to institutional policies and structures. Whatever the causes, racial disparities in health care call for quality improvement initiatives. In that spirit, this report proposes the pursuit of "systems reform"—the redesign of the underlying systems of care themselves in order to better serve all patients.

Health care quality regulators, such as the Centers for Medicare and Medicaid Services (CMS) and other agencies, have embraced systems reform, largely through mandates that require health care providers to implement Quality Assessment and Performance Improvement (QAPI) initiatives. In these two-part programs, "quality assessment" involves the use of scientifically validated indicators of care, such as vaccination rates, preventive screenings, and medication rates, to measure quality of care. "Performance improvement" refers to the programs' data-driven interventions that aim to quantifiably adjust those indicators for the better.

Systems reform is a monumental shift from old-style quality oversight, which focused on the negative and blamed individuals for errors. Instead, this new approach is non-punitive, forward-looking, and positive. Acknowledging that "to err is human," systems reform envisions quality improvement as an organizational responsibility. Its proponents believe that more can be accomplished by raising the mean performance of all caregivers than by merely eliminating the worst-performing caregivers. Furthermore, these proponents assert that quality improvement is an ongoing process of evaluation, design adjustment, reevaluation, and further adjustment, as needed. The aim is not just to reduce errors, but to deliver ever better care.

A systems reform approach to reducing racial and ethnic disparities requires performance data that stratify quality-of-care indicators according to patient race and ethnicity. However, such information does not currently exist. No government agency or private accreditation body requires it. And while a few providers have begun to report equity measures voluntarily, most do not.

Performance data stratified by race and ethnicity could provide valuable information about the extent and impact of health care disparities. Moreover, this information could indicate which system designs, training modules, and protocols reduce racial and ethnic disparities and which ones fail to do so. Public reporting of equity performance measures would hold providers and institutions accountable to the communities they serve and to those they should be serving.

Yet, even though QAPI requirements for systems reform are becoming widespread, none of them obliges individual health care plans or providers to measure racial and ethnic disparities in the care they provide. Nor do these mandates require the implementation of quality improvement projects directed specifically at reducing or eliminating treatment inequities.

Incorporating equity measures into existing QAPI requirements does not require legislative action, although a congressional mandate would send a strong message about eliminating racial and ethnic disparities in medical care. For Medicaid and Medicare managed care, CMS and the states already have the necessary regulatory authority—they simply need to issue policy mandating equity QAPIs. For hospitals, CMS could use financial incentives, similar to what it has done with hospital reporting of overall performance, to encourage voluntary equity QAPIs. Finally, private accreditation bodies could take the lead in mandating equity QAPIs as part of their voluntary accreditation process.

Existing law, along with modified federal and state agency policies, offers the means to address inequities in health care. QAPI equity performance measures in particular can assess racial disparities in quality of care and help redress them through systems reform initiatives.

Publication Details



Equity Measures and Systems Reform as Tools for Reducing Racial and Ethnic Disparities in Health Care, Sidney D. Watson, J.D., The Commonwealth Fund, August 2005