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SPECIAL SYMPOSIUM: INTERVENTIONS TO REDUCE RACIAL AND ETHNIC DISPARITIES IN
HEALTH CARE
A Roadmap and Best Practices for Organizations
to Reduce Racial and Ethnic Disparities in Health Care
Marshall H. Chin, MD, MPH
1,2,3
, Amanda R. Clarke, MPH
1,2
, Robert S. Nocon, MHS
1,2,3
,
Alicia A. Casey, MPH
1,2
, Anna P. Goddu, MSc
1,2,3
, Nicole M. Keesecker, MA
1,2
, and
Scott C. Cook, PhD
1,2
1
Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change National Program Office, University of Chicago,
Chicago, IL, USA;
2
Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA;
3
Section of General Internal Medicine,
Department of Medicine, University of Chicago, Chicago, IL, USA.
Over the past decade, researchers have shifted their focus
from documenting health care disparities to identifying
solutions to close the gap in care. Finding Answers:
Disparities Research for Change, a national program of
the Robert Wood Johnson Foundation, is charged with
identifying promising interventions to reduce disparities.
Based on our work conducting systematic reviews of the
literature, evaluating promising practices, and providing
technical assistance to health care organizations, we
present a roadmap for reducing racial and ethnic
disparities in care. The roadmap outlines a dynamic
process in which individual interventions are just one
part. It highlights that organizations and providers need
to take responsibility for reducing disparities, establish a
general infrastructure and culture to improve quality,
and integrate targeted disparities interventions into
quality improvement efforts. Additionally, we summarize
the major lessons learned through the Finding Answers
program. We share best practices for implementing
disparities interventions and synthesize cross-cutting
themes from 12 systematic reviews of the literature.
Our research shows that promising interventions fre-
quently are culturally tailored to meet patients’needs,
employ multidisciplinary teams of care providers, and
target multiple leverage points along a patient’s pathway
of care. Health education that uses interactive techni-
ques to deliver skills training appears to be more effective
than traditional didactic approaches. Furthermore, pa-
tient navigation and engaging family and community
members in the health care process may improve out-
comes for minority patients. We anticipate that the
roadmap and best practices will be useful for organiza-
tions, policymakers, and researchers striving to provide
high-quality equitable care.
KEY WORDS: disparities; quality of care; race; intervention; equity.
J Gen Intern Med 27(8):992–1000
DOI: 10.1007/s11606-012-2082-9
© Society of General Internal Medicine 2012
In 2005, the Robert Wood Johnson Foundation (RWJF)
created Finding Answers: Disparities Research for
Change (www.solvingdisparities.org) as part of its portfolio
of initiatives to reduce racial and ethnic disparities in health
care.
1
RWJF charged Finding Answers with three major
functions: administer grants to evaluate interventions to
reduce racial and ethnic disparities in care, perform system-
atic reviews of the literature to determine what works for
reducing disparities, and disseminate these findings national-
ly. Over the past seven years, Finding Answers has funded 33
research projects and performed 12 systematic literature
reviews, including the five papers in this symposium.
2–6
We
are now beginning to leverage this research base to provide
technical assistance to organizations that are implementing
disparities reduction interventions, such as those participating
in RWJF’s Aligning Forces for Quality program.
7
This paper summarizes the major lessons learned from the
systematic reviews and provides a disparities reduction
framework. Building on our prior work,
8–10
we present a
roadmap for organizations seeking to reduce racial and ethnic
disparities in health care. This roadmap may be tailored for
use across diverse health care settings, such as private
practices, managed care organizations, academic medical
centers, public health departments, and federally qualified
health centers. Specifically, we outline the following steps:
1) Recognize disparities and commit to reducing them
2) Implement a basic quality improvement structure and
process
3) Make equity an integral component of quality improve-
ment efforts
JGIM
Electronic supplementary material The online version of this article
(doi:10.1007/s11606-012-2082-9) contains supplementary material,
which is available to authorized users.
992
4) Design the intervention(s)
5) Implement, evaluate, and adjust the intervention(s)
6) Sustain the intervention(s)
FINDINGS FROM THE SYSTEMATIC REVIEWS
The five systematic reviews in the present symposium
examined interventions to improve minority health and
potentially reduce disparities in asthma, HIV, colorectal
cancer, prostate cancer, and cervical cancer.
2–6
While
many valuable ideas to address racial and ethnic health
disparities are being pursued outside of the healthcare
system, Finding Answers focuses specifically on what can
be accomplished once regular access to healthcare services
is achieved. Thus, the reviews focused on interventions
that occur in or have a sustained linkage to a healthcare
delivery setting; programs that were strictly community-
based were outside the scope of the project. Additionally,
the reviews examined racial and ethnic disparities in care
and improvements in minority health, rather than geo-
graphic, socioeconomic, or other disparities. For a de-
scription of search strategies employed in these reviews,
see the technical web appendix which can be accessed
online (Electronic Supplementary Material).
Each review identified promising practices to improve
minority health within the healthcare setting. The asthma paper
found that educational interventions were most common, with
culturally tailored, skills-based education showing promise.
5
Outpatient support, as well as education for inpatient and
emergency department patients, were effective. Similarly, the
HIV review noted that interactive, skills-based instruction was
more likely to be effective than didactic educational approaches
for changing sexual health behavior.
3
The paper identified a
dearth of interventions that target minority men who have sex
with men. The colorectal cancer review found that patient
education and navigation were the most common interventions
and that those with intense patient contact (e.g., in person or by
telephone) were the most likely to increase screening rates.
4
The colorectal cancer review identified no articles that
described interventions to reduce disparities in post-screening
follow-up, treatment, survivorship, or end-of-life care. Based on
low to moderate evidence, the cervical cancer review reported
that navigation combined with either education delivered by lay
health educators or telephone support can increase the rate of
screening for cervical cancer among minority populations.
2
Telephone counseling might also increase the diagnosis and
treatment of premalignant lesions of the cervix for minority
women. The prostate cancer review focused on the importance
of informed decision making for addressing prostate cancer
among racial and ethnic minority men.
6
Educational programs
were the most effective intervention for improving knowledge
among screening-eligible minority men. Cognitive behavioral
strategies improved quality of life for minority men treated for
localized prostate cancer. However, more research is needed
about interventions to improve informed decision making and
quality of life among minority men with prostate cancer.
CROSS-CUTTING THEMES
We looked across these reviews and Finding Answers’
previous research,
11–17
and identified several cross-cutting
themes. Our findings showed that promising interventions
frequently were multi-factorial, targeting multiple leverage
points along a patient’s pathway of care. Culturally-tailored
interventions and those that employed a multi-disciplinary
team of care providers also tended to be effective. Addition-
ally, we found that education using interactive methods to
deliver skills training were more effective than traditional,
didactic approaches in which the patient was a passive learner.
Patient navigation and interventions that actively involved
family and community members in patient care showed
promise for improving minority health outcomes. Finally, the
majority of interventions targeted changing the knowledge
and behavior of patients, generally with some form of
education. Interventions directed at providers, microsystems,
organizations, communities, and policies were far less
common, thus representing an opportunity for future research.
ROADMAP FOR REDUCING DISPARITIES
Tab le 1summarizes the major steps health care organizations
need to undertake to reduce disparities. Past efforts have
focused on Step 1 (e.g. collecting performance data stratified
by race, ethnicity, and language) or Step 4 (designing a
specific intervention). Our roadmap highlights that these are
crucial steps, but will have limited impact unless the other
steps are addressed. Effective implementation and long-term
sustainability require attention to all six steps.
1) Recognize disparities and commit to reducing them
When health care organizations and providers realize
there are disparities in their own practices,
18
they become
motivated to reduce them.
19
Therefore, the Patient Protec-
tion and Affordable Care Act of 2010 makes the collection
of performance data stratified by race, ethnicity, and
language (REL) a priority.
20
Similarly RWJF’s Aligning
Forces for Quality Program initially focused its disparities
efforts on the collection of REL data in different commu-
nities. The Institute of Medicine (IOM) recently recom-
mended methods to collect REL data,
21
and groups such as
the Health Research and Educational Trust (HRET) have
developed toolkits to guide organizations in this effort.
22
Besides race-stratified performance data, training in
health disparity issues (e.g., through cultural competency
training) may help providers identify and act on disparities
in their own practices. However, while cultural competency
993Chin et al.: A Roadmap to Reduce Racial DisparitiesJGIM
training and stratified performance data may increase the
readiness of providers and organizations to change their
behavior,
19
these interventions will need to be accompanied
by more intensive approaches to ameliorate disparities.
Sequist et al. found that cultural competency training and
performance reports of the quality of diabetes care stratified
by race and ethnicity increased providers’awareness of
disparities, but did not improve clinical outcomes.
23
There-
fore, our roadmap for reducing disparities highlights the
importance of combining REL data collection with inter-
ventions targeted towards specific populations and settings.
2) Implement a basic quality improvement structure and
process
Interventions to reduce disparitieswillnotgetveryfarunless
there is a basic quality improvement structure and process
upon which to build interventions.
24,25
Basic elements include
a culture where quality is valued, creation of a quality
improvement team comprised of all levels of staff, a process
for quality improvement, goal setting and metrics, a local
team champion, and support from top administrative and
clinical leaders. If robust quality improvement structures and
processes do not exist, then they must be created and nurtured
while disparities interventions are developed.
3) Make equity an integral component of quality improve-
ment efforts
For too long, disparities reduction and quality improvement
have been two different worlds. People generally thought
about reducing disparities separately from efforts to improve
quality, and oftentimes different people in an organization
were responsible for implementing disparity and quality
initiatives. A major development over the past decade is the
increasing recognition that equity is a fundamental compo-
nent of quality of care. Efforts to reduce disparities need to
be mainstreamed into routine quality improvement efforts
rather than being marginalized.
26
That is, we need to think
about the needs of the vulnerable patients we serve as we
design interventions to improve care in our organizations,
and address those needs as part of every quality improvement
initiative. The Institute of Medicine’sCrossing the Quality
Chasm report stated that equity was one of six components
of quality,
27
and the IOM’s 2010 report Future Directions for
the National Healthcare Quality and Disparities Reports
highlighted equity further by elevating it to a cross-cutting
dimension that intersects with all components of quality
care.
28
Major health care organizations have instituted
initiatives that promote the integration of equity into quality
efforts including the American Board of Internal Medicine
(Disparities module as part of the recertification process),
American College of Cardiology (Coalition to Reduce Racial
and Ethnic Disparities in Cardiovascular Disease Outcomes
[CREDO] initiative),
29
American Medical Association (Com-
mission to End Health Care Disparities), American Hospital
Association (Race, ethnicity, and language data collection),
22
Joint Commission (Advancing Effective Communication,
Cultural Competence, and Patient- and Family-Centered
Care: a Roadmap for Hospitals),
30
and National Quality
Forum (Healthcare Disparities and Cultural Competency
Consensus Standards Development). For many health care
organizations and providers, this integration of equity and
quality represents a fundamental change from generic quality
improvement efforts that improve only the general system of
care, to interventions that improve the system of care and are
targeted to specific priority populations and settings.
4) Design the intervention(s)
While several themes have emerged regarding successful
interventions to reduce health care disparities based on our
systematic reviews and grantees, solutions must be individ-
ualized to specific contexts, patient populations, and
Table 1. Six Steps for Reducing Racial and Ethnic Disparities in Care
1) Recognize disparities and commit to reducing them
a. Stratify performance data by race, ethnicity, and language
b. Provide disparities training for providers and staff
2) Implement a basic quality improvement structure and process
a. Create a culture of quality
b. Designate a quality improvement team
c. Establish a quality improvement process
d. Set goals and metrics
e. Select a local champion
f. Obtain leadership support
3) Make equity an integral component of quality improvement efforts
a. Recognize equity as a cross-cutting dimension of quality
b. Ensure that disparities efforts are not marginalized
4) Design the intervention(s)
a. Determine root causes of disparities in specific context
b. Consider six levels of influence: patient, provider,
microsystem, organization, community, policy
c. Review existing literature
(1) Robert Wood Johnson Foundation - Interventions
database, systematic reviews
(www.solvingdisparities.org)
(2) Agency for Healthcare Research and Quality -
Health Care Innovations Exchange
(www.innovations.ahrq.gov/), forthcoming
Evidence-Based Practice Center Review
(3) Veterans Administration - forthcoming review
d. Learn from peer organizations
e. Use evidence-based strategies
(1) Multifactorial interventions that address key drivers
of disparities
(2) Culturally targeted interventions
(3) Team-based care
(4) Patient navigation
(5) Work with families and non-health care partners
(6) Interactive, skills-based training for patients rather
than passive, didactic education
f. Consider specific types of interventions (Table 3)
5) Implement, evaluate, and adjust the intervention(s)
a. Consider implementation models such as the Consolidated
Framework for Implementation Research
b. Consider best practices (Table 4)
c. Evaluate and adjust intervention
6) Sustain the intervention(s)
a. Institutionalize intervention
b. Create financial model
994 Chin et al.: A Roadmap to Reduce Racial Disparities JGIM
organizational settings.
31
For example, solutions for reduc-
ing diabetes disparities for African-Americans in Chicago
may differ from the answers for African-Americans in the
Mississippi Delta. We recommend determining the root
causes of disparities in the health care organization or
provider’s patient population and designing interventions
based on a conceptual model that targets six levels of
influence: patient, provider, microsystem, organization,
community, and policy (Table 2).
8,9
Each level represents
a different leverage point that can be addressed to reduce
disparities. The relative importance of these levels may vary
across diverse organizations and patient populations.
Specific intervention strategies can then be developed to
target different levels of influence. Table 3offers an
overview of strategies identified through the review of
approximately 400 disparities intervention studies, including
the 33 Finding Answers projects and 12 systematic literature
reviews. Common intervention strategies include delivering
education and training, restructuring the care team, and
increasing patient access to testing and screening. About half
of the interventions targeted only one of the levels of
influence described above; most efforts were directed at
patients in the form of education or training. Research
evaluating pay-for-performance, on the other hand, was scant
and requires further attention, especially given current
interest in incentive-based programs. Going forward, Finding
Answers aims to categorize each of the approximately 400
studies by level of influence and strategy, and to identify
which combinations are promising for disparities reduction.
Organizations can find practical resources and promising
intervention strategies on the Finding Answers website
(www.solvingdisparities.org) or the Agency for Healthcare
Research and Quality (AHRQ) Health Care Innovations
Exchange (www.innovations.ahrq.gov). Systematic reviews
such as those by Finding Answers and forthcoming ones
from the AHRQ Evidence-Based Practice Center Program
and the Veterans Administration can inform what types of
interventions are most appropriate in different situations. In
addition, organizations can learn about successful projects
from peers through learning collaboratives,
24
site visits,
case studies, and webinars.
While there is no silver bullet to reduce disparities,
successful interventions reveal important themes. As previ-
ously noted, we looked across 12 systematic reviews of the
literature and identified promising practices that can inform
the design of future disparities interventions.
2–6,11–17
These
include culturally tailoring programs to meet patients’
needs, patient navigation, and engaging multidisciplinary
teams of care providers in intervention delivery. Effective
interventions frequently target multiple leverage points
along a patient’s pathway of care and actively involve
families and community members in the care process.
Additionally, successful health education programs often
incorporate interactive, skills-based training for minority
patients.
5) Implement, evaluate, and adjust the intervention(s)
The National Institutes of Health recently held its fifth
annual conference on the science of dissemination and
implementation to promote further research in this field,
create opportunities for peer-to-peer learning, and showcase
available models and tools. One such model is the
Consolidated Framework for Implementation Research
(CFIR), for which Damschroder et al. reviewed conceptual
models of relevant factors in implementing a quality
improvement intervention and synthesized existing frame-
works into a single overarching model.
32
The CFIR covers
five domains: intervention characteristics (e.g. relative
advantage, adaptability, complexity, cost), outer setting
(e.g. patient needs and resources, external policy and
Table 2. Levels of Influence of an Intervention
Intervention Level Definition Examples
Patient Change the knowledge and/or behaviors of patients
to improve their health outcomes
Symptom monitoring
Incentives
Culturally targeted education and outreach
Self-management and goal setting
Patient narratives
Provider Change the knowledge and/or behavior of providers
to improve patient outcomes
Cultural competency training
Disparity report cards
Microsystem Add new members to or shift responsibilities among
the immediate care team, such as the primary care
provider, nurse, and staff
Integration of community health workers or other
staff into the care team
Nurse-led interventions
Organization Change organization operations; may require coordination
among management, providers,
information technology, and/or human resources
Redesigning the system of operations
Instituting new forms of technology
Improving the clinical encounter
Systematic literacy screening of patients
Community Work with people and organizations outside traditional
health settings such as churches, schools, and social
service agencies
Engaging local stakeholders to integrate community
and health care resources
Policy Influence laws, regulations, and/or resource allocation
on a regional or national basis
Medicare reimbursement regulations
Accreditation standards for providers and health care
organizations
Breast cancer screening laws
995Chin et al.: A Roadmap to Reduce Racial DisparitiesJGIM
incentives), inner setting (e.g. culture, implementation
climate, readiness for implementation), characteristics of
the individuals involved (e.g. knowledge and beliefs about
the intervention, self-efficacy, stage of change), and the
process of implementation (e.g. planning, engaging, exe-
cuting, evaluating). Too often organizations focus on the
content of an intervention without planning its implemen-
tation in sufficient detail. A model such as CFIR supplies a
checklist of factors to consider in implementing an
intervention to reduce disparities.
Through work with our 33 grantees, we have devel-
oped a series of best practices for implementing inter-
ventions to reduce disparities. These lessons were pulled
from detailed qualitative data gathered through the
Finding Answers program, and represent perspectives
from organization leadership, providers, administrators,
and front-line staff. We found common implementation
challenges and solutions across health care settings.
Tab le 4summarizes best practices for disparities reduction
efforts, provides the rationale and expected outcomes, and
offers recommended strategies for delivering a high-quality
equity initiative.
Implementation is an iterative process and organiza-
tions are unlikely to get the perfect solution on their first
Table 3. Overview of Disparities Intervention Strategies
Intervention Strategy Definition Examples
Deliver education and training Providing information, tools, and/or teaching skills. Patient education in self-management
Provider training in cultural competency
Education via plays and skits
Communication skills training
Decision-making aid
Prescribed diet/exercise
Continuing Medical Education (CME)
Engage the community Involving organizations and/or individuals outside
the health care delivery setting.
Media education campaign
Church-based care delivery
School-based care delivery
Health/Learning collaborative
Coalition building/advocacy
Outreach to households
Provide psychological support Delivering therapy to promote healthy behavior
and psychological well-being of patients,
their partners, and/or their families.
Group therapy
Partner counseling
Family therapy
Coping skills development
Motivational interviewing
Telepsychiatry
Risk/harm reduction
Provide reminders and feedback Prompting adherence to recommended care
guidelines and sharing information about performance.
Patient reminder to schedule preventive care
Provider reminder of care protocol
Patient health maintenance card/health mini-record
Performance report cards stratified by race,
ethnicity, and language
Restructure the care team Shifting responsibilities among members of the care
team or adding members to the existing care team
to enhance care delivery.
Nurse-led interventions
Pharmacist consultation
Increased involvement of primary care provider
in specialty care
Peer coach/peer educator
Community/lay health workers
Patient navigator
Improve language and literacy
services
Improving communication among providers, specialists
and/or patients.
Health literacy screening
Enhanced interpreter services
Increase access to testing
and screening
Addressing financial and logistical barriers to testing
and screening.
Free screening
Integrated screening
Screen-and-Treat
Rapid test results
Risk assessment
Provide financial incentives Offering money or free/subsidized goods or services
to influence behavior.
Vouchers for care
Reduced out-of-pocket expenses
Free give-aways
Pay for performance
Cultural targeting Customizing the content, approach, or messaging
of an intervention based on characteristics
of the population receiving care.
Culturally targeted education materials
Patient-provider racial/ethnic concordance
Religious messaging
Use technology Using computerized or information technology-assisted
tools to improve care.
Home biomarker measurement transmitted to clinic
Peer storytelling on DVDs
Remote video language interpretation
Computerized reminders
Computer kiosks in clinic waiting room
Interactive computerized education/counseling
Other Intervention strategies that did not meet the criteria
defined above.
Home-based care
Clinic open door policy
Increased referrals/streamlined referral systems
996 Chin et al.: A Roadmap to Reduce Racial Disparities JGIM
attempt. Thus, evaluation of the intervention and adjust-
ments to the program based on performance data stratified
by race, ethnicity, and language are integral parts of the
implementation process. Setting realistic goals is essential
to accurately assess program effectiveness. Processes of
care (e.g. measurement of hemoglobin A1c in patients
with diabetes) generally improve more rapidly than patient
outcomes (e.g. actual hemoglobin A1c value), and may
therefore be better markers of short-term disparities
reduction success, while outcomes could be longer-term
targets.
6) Sustain the intervention(s)
Health care organizations, administrative leaders, and
providers need to proactively plan for the sustainability of
the intervention. Sustainability is dependent upon institu-
tionalizing the intervention and creating feasible financial
models. Too often interventions are dependent upon the
initial champion and first burst of enthusiasm. If that
champion leaves the organization or if staff tire after the
early stages of implementation, then the disparities initiative
is at risk for discontinuation. Institutionalization requires
Table 4. Best Practices for Implementing Interventions to Reduce Racial and Ethnic Disparities in Health Care
Practice Rationale Possible Strategies Outcome
Assess organizational
capacity
Interventions are more likely to succeed
if the organization as a whole is ready
for change.
Assess institutional resources (e.g. trained
staff, materials, technology platforms)
and match them with the needs of the
intervention.
Organizations are equipped
to implement and sustain
the intervention.
Ensure ongoing financial support.
Foster a culture of equity Success is more likely if staff recognize
that disparities exist within the
organization and view inequality as an
injustice that must be redressed.
Institute systems to offer feedback to
providers and incentivize disparities
reduction.
Staff shares a definition of
equitable care and places
high value on its delivery.
Explicitly define equitable health care as a
goal in mission statements.
Build a work force that reflects the
diversity of the patient population.
Appoint staff to disparities
reductions initiatives
A plan to improve equity requires
human resources.
Consider quality improvement specialists
and on-site equity champions to fill
these roles. Mainstream equity into all
quality improvement efforts.
Intervention is given
adequate time and effort.
Anticipate leadership and staff turn-over:
e.g. cross-train staff; incorporate
intervention training into staff
orientation; include program
responsibilities in job descriptions.
Staff is not overtaxed.
Identify and appeal to the
equity rationale that is
most important to your
audience
Staff members are motivated for a
variety of reasons:
Leverage staff motivation to support the
program:
Buy-in across the
organization is secured.
Leadership may respond well to
programs that guarantee a positive
return on investment and leverage
existing resources.
Present data that demonstrate potential for
positive financial impact.
Consistent and accurate
uptake of interventions is
encouraged.
Providers are often concerned with
maximizing efficiency during the
office visit.
Enhance the care team and promote care
management outside of the clinic.
Front-line staff may be wary of
impacting patient flow and room
availability.
Minimize burden and show respect for
staff time.
Everyone cares about patient outcomes. Inspire enthusiasm to help patients.
Incorporate disparities
interventions into existing
systems and anticipate
ripple effects
New programs may create redundant
efforts or conflicting goals with
existing quality improvement
initiatives.
Assess existing systems (e.g., electronic
medical records) and identify
opportunities for integration during the
planning phase.
Workload and schedules
are manageable.
Disruptions and
inconsistencies are
minimized.
Involve members of the
target population during
program planning
Programs that are not culturally
targeted risk rejection by patients.
Involve the target population in program
design in a manner that is meaningful
and inclusive.
Community engagement is
advanced.
Input by minority health workers is not
a proxy for patient involvement.
Engage patients, not just minority health
workers.
Programs are relevant and
effective.
Strike a balance between
adherence and adaptability
While adherence to protocol ensures
consistency,flexibility is key when
working with diverse patients.
Regularly collect process measures,
identify opportunities for improvement,
and adapt the intervention accordingly.
Programs are consistent,
yet flexible.
Use standardized checklists to monitor
adherence.
Be realistic about the time
necessary to move the dial
on disparities
Improvements in minority health take
time because of multiple challenges
inside and outside the clinic.
Plan long-term follow-up to demonstrate
statistically significant improvements in
health outcomes.
A realistic timeline
manages expectations
and maintains ongoing
support.
997Chin et al.: A Roadmap to Reduce Racial DisparitiesJGIM
promoting an organizational culture that values equity,
creating incentives to continue the effort, whether financial
and/or non-financial, and weaving the intervention into the
fabric of everyday operations so that it is part of routine
care as opposed to a new add-on (e.g. Step 3 in Table 1).
In the long-term, however, interventions must be finan-
cially viable. The business case for reducing disparities is
evolving and must be viewed from both societal and
individual organization/provider perspectives.
33–35
From a
societal perspective, the business case for reducing dispar-
ities centers on direct medical costs, indirect costs, and the
creation of a healthy national workforce in an increasingly
competitive global economy. Laveist et al. estimate that
disparities for minorities cost the United States $229 billion
in direct medical expenditures and $1 trillion in indirect
costs between 2003 and 2006.
36
America’s demographics
are becoming progressively more diverse. The United States
Census Bureau estimates that by 2050, the Hispanic
population will reach 30 %, the black population 13 %,
and the Asian population 8 %.
37
Thus, from global and
national economic perspectives, disparities reduction will
become increasingly important if we are to have a healthy
workforce that can successfully compete in the international
marketplace and support the rapidly growing non-working
aging population on the Social Security and Medicare
entitlement programs.
From the perspective of the individual health care organiza-
tion or provider, the immediate incentives are more complex.
Integrated care delivery systems have an incentive to reduce
disparities to decrease costly emergency department visits and
hospitalizations. Large insurers are incentivized to provide
high quality care for everyone to be more competitive in
marketing their products to employers with increasingly
diverse workforces. However, outpatient clinics and providers
in the current, predominantly fee-for-service world, especially
those serving the uninsured and underinsured, frequently do
not have clear incentives to reduce disparities since the money
saved from the prevented emergency department visit or
hospitalization does not accrue to them.
34
Currently, it is difficult to accurately predict the results of
health care reform and efforts to contain the Medicare and
Medicaid budgets, but several trends indicate that organ-
izations would be wise to integrate disparities reduction into
their ongoing quality improvement initiatives. Major na-
tional groups such as the Department of Health and Human
Services (HHS), Agency for Healthcare Research and
Quality, Centers for Disease Control (CDC), Centers for
Medicare and Medicaid Services, and Institute of Medicine
have consistently stressed the importance of reducing health
care disparities and using quality improvement as a major
tool to accomplish this goal.
28,38–42
The Affordable Care
Act emphasizes collection of race, ethnicity, and language
data.
20
Private demonstration projects, such as the Robert
Wood Johnson Foundation Aligning Forces for Quality
Program,
7
aim for multistakeholder coalitions of providers,
payers, health care organizations, and consumers to im-
prove quality and reduce disparities on regional levels.
Intense policy attention has been devoted to accountable
care organizations,
43
the patient-centered medical home,
44
and bundled payments.
45
These organizational structures
and financing mechanisms emphasize coordinated, popula-
tion based care that may reduce disparities.
Reducing racial and ethnic disparities in care is the right
thing to do for patients, and, from a business perspective,
health care organizations put themselves at risk if they do
not prepare for policy and reimbursement changes that
encourage reduction of disparities. We believe that health
care organizations and providers would be imprudent if they
did not plan for payment and coverage possibilities such as:
1) Incentives and reimbursements for team-based care.
Team-based care is one of the most consistently
successful types of disparities interventions,
9
but current
payment mechanisms often do not create viable business
models for sustainability. We believe that it is likely that
future policies encouraging efficiency will increasingly
reimburse or incentivize team-based care management
activities; reimburse or incentivize use of non-physician
members of the team, such as community health work-
ers, peer educators and patient navigators; and ensure
that downstream savings from care teams, such as
averted hospitalizations and emergency department
visits, flow back to those that generated the savings.
2) Implementation of pay-for-performance programs for
reducing racial and ethnic disparities. Pay-for-performance
is likely to become part of efforts to move from paying for
volume to paying for quality. It will be important to
incorporate safeguards such as pay-for-improvement to
avoid cherry picking of easy patients, patient dropping,
and harming of poorly resourced organizations caring for
predominantly vulnerable populations.
16
3) Incentives to create linkages between community and
health care system. The new CDC Health Disparities
and Inequalities Report and HHS National Strategy for
Quality Improvement in Health Care exemplify the rise
of combined public health—health care approaches to
reduce disparities.
39,41,46
Integration of community
health workers and other peer-based programming into
the health care team shows potential,
4,12
and there is
evidence that directly involving families, schools, and
community-based organizations in health care interven-
tions can improve health outcomes.
17
CONCLUSION
As outlined in our roadmap, it is critical to create an
organizational culture and infrastructure for improving
998 Chin et al.: A Roadmap to Reduce Racial Disparities JGIM
quality and equity. Organizations must design, implement,
and sustain interventions based on the specific causes of
disparities and their unique institutional environments and
patient needs. To be most effective, all of these elements
eventually need to be addressed;
24
however, we do not
want to encourage paralysis for those who might perceive a
daunting set of obstacles to overcome. Instead, our
experience has been that it useful for an organization to
start working on disparities by targeting whatever step or
action feels right to them and is thus a priority.
46
Eventually
the other steps will need to be addressed, but reducing
disparities is often a dynamic process that evolves over
time. While more disparities intervention research is
needed, we have learned much over the past 10 years about
which approaches are likely to succeed. The time for action
is now.
Acknowledgements:
Contributors: We would like to thank Melissa R. Partin, PhD, who
served as the JGIM Deputy Editor for the six manuscripts in this
Special Symposium: Interventions to Reduce Racial and Ethnic
Disparities in Health Care. Dr. Partin provided valuable advice and
feedback throughout this project. Marshall H. Chin, MD, MPH, and
Amanda R. Clarke, MPH, served as the Robert Wood Johnson
Foundation Finding Answers: Disparities Research for Change
Systematic Review Leadership Team that oversaw the teams
writing the articles in this symposium.
Funding Source: Support for this publication was provided by the
Robert Wood Johnson Foundation Finding Answers: Disparities
Research for Change Program. The Robert Wood Johnson Founda-
tion had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; and prepa-
ration, review, approval, or decision to submit the manuscript for
publication.
Prior Presentations: Presented in part at the Society of General
Internal Medicine Midwest Regional Meeting, September 23, 2010,
Chicago, Illinois; the Society of General Internal Medicine Annual
Meeting, May 5, 2011, Phoenix, Arizona; the American Public Health
Association Annual Meeting, November 1, 2011, Washington, D.C.;
and the Institute for Healthcare Improvement Annual National
Forum, December 4, 2011, Orlando, Florida.
Conflict of Interest: The authors report no conflicts of interest with
this work. Dr. Chin was also supported by a National Institute of
Diabetes and Digestive and Kidney Diseases Midcareer Investigator
Award in Patient-Oriented Research (K24 DK071933), Diabetes
Research and Training Center (P60 DK20595), and Chicago Center
for Diabetes Translation Research (P30 DK092949).
Corresponding Author: Marshall H. Chin, MD, MPH; Section of
General Internal Medicine, Department of Medicine, University of
Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL
60637, USA (e-mail: mchin@medicine.bsd.uchicago.edu).
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