Racial/Ethnic Disparities in Health Care: Narrowing the Gap through Solutions

Joseph R. Betancourt, M.D., M.P.H.

Director, The Disparities Solutions CenterSenior Scientist, Institute for Health Policy

Director for Multicultural Education, Massachusetts General Hospital

Associate Professor of Medicine, Harvard Medical School

Outline

Disparities in Health and Health Care

Key Lessons from Unequal Treatment

Identifying and Addressing Disparities:

A Case Study of Mass General Hospital

Diabetes-Related Death Rate, 2008

Deaths per 100,000 population

22.8

50.1

33.6

50.3

18.4

0

10

20

30

40

50

WHITE AFRICANAMERICAN

HISPANIC AI/AN ASIAN/PI

What causes these Racial/Ethnic Disparities in Health?

Social Determinants

Access to Care

Health Care?

Disparities in Health Care 2002

Racial/Ethnic disparities found across a wide range of health care settings, disease areas, and clinical services, even when various confounders (SES, insurance) controlled for.

Findings: Many sources contribute to disparities—no one suspect, no one solution

Disparities and Clinical Care

Key Lessons from Unequal Treatment

Minorities Face Greater Difficulty in Communicating with Physicians

19%16%

23%

33%

27%

0%

20%

40%

Total White AfricanAmerican

Hispanic AsianAmerican

Base: Adults with health care visit in past two years.* Problems include understanding doctor, feeling doctor listened, had questions but did not ask.

Source: The Commonwealth Fund Health Care Quality Survey.

Percent of adults with one or more communication problems*

Decisionmaking and Stereotyping

Automatic aspects; groupindividual “Cognitive Misers”cognitive shortcuts to

save resources; principle of “least effort” Primal->race, gender, age Activated most when:

– Stressed– Under time constraints– Multitasking

The Patient Perspective: Unequal Treatment

Kaiser Family Foundation Survey, 2000

58

36

65

35

22

15

0 20 40 60 80

Fu

ture

un

fair

Tx

bas

ed o

nra

ce/e

thn

icit

y

Pas

t u

nfa

ir T

xb

ased

on

race

/eth

nic

ity

Whites

Blacks

Latinos

Percent

IOM’s Unequal Treatmentwww.nap.edu

Recommendations

Increase awareness of existence of disparities

Address systems of care

– Support race/ethnicity data collection, quality improvement, evidence-based

guidelines, multidisciplinary teams, community outreach

– Improve workforce diversity

– Facilitate interpretation services

Provider education

– Health Disparities, Cultural Competence, Clinical Decisionmaking

Patient education (navigation, activation)

Research

– Promising strategies, Barriers to eliminating disparities

Case Study

Massachusetts General Hospital

Developing Solutions: Quality and Disparities

System

Provider Patient

-Screen for non-adherence

-Provide focused education, activation, navigation

-CC Education

-Facilitate adherence to guidelines

-R/E Data Collection, Registries, Dashboards, QI

Culturally Competent Programs

Provider Education Quality Interactions Cross-Cultural Training offered as option as part of

MGPO QI Incentive this past quarter; case-based, evidence-based, interactive e-learning program which allows learners to develop a skill set to provide quality to patients of diverse cultural backgrounds

987 doctors completed; more than 88% said program increased awareness of issues, would improve care they provide to patients, and would recommend to colleagues; average pretest score 51%, posttest score 83%

1. Available at: http://www.qualityinteractions.org/prod_overview/clinical_program_features.html.

Culturally Competent Disease Management:The MGH Chelsea Diabetes Program

Collaboration of the Disparities Solutions Center, Chelsea Healthcare Center, and the MGPO

A quality improvement / disparities reduction

program with 3 primary components:

• Telephone outreach to increase rate of HbA1c testing

• Individual coaching to address patients’ needs and

concerns regarding diabetes self-management to

improve HbA1c

• Group education meeting ADA requirements

*Also focus on link between mental health, chronic disease management, and prevention

Diabetes Control Improving for All: Gap between Whites and Latinos Closing

24% 24%

20%

37%

34%

29%

0%

10%

20%

30%

40%

50%

2005 2006 2007

Year

% o

f P

atie

nts

wit

h P

oo

rly

Co

ntr

olle

d D

iab

etes

(H

bA

1c

> 8

) Whites

Latinos

* Chelsea Diabetes Management Program began in first quarter of 2006; in 2008 received Diabetes Coalition of MA Programs of Excellence Award

*

Looking Ahead

NCQA

– New efforts in disparities; measures completed public comment

Joint Commission

– New disparities/cultural competence accreditation standards 2010-11

National Quality Forum

– Released cultural competence quality measures

Health Care Reform

– Multiple provisions to address disparities CHW’s to support medical homes

– Provide support services to primary care providers to deliver high quality, culturally

appropriate care

Primary Care Training and Enhancement– Priority given to programs that provide training in cultural competency

Rewarding Quality through Market Based Incentives– Incentives for implementation of activities to reduce health and healthcare disparities via

language services, community outreach, and cultural competency trainings

Summary

There is a significant body of evidence that has

identified disparities in health care

Health care organizations and providers can

contribute to their elimination

IOM recommendations will improve the care not only

of minorities, but of all AmericansMore information about our programs can be found at:

www.mghdisparitiessolutions.org