Racial/Ethnic Disparities and Health Policy A View from the Field

1. Racial/Ethnic Disparities and Health PolicyA View from the Field Joseph R. Betancourt, M.D., M.P.H. Director, The Disparities Solutions Center Senior Scientist, Institute for Health Policy Director for Multicultural Education, Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School

2. Outline • Disparities in Health and Health Care • IOM’s Unequal Treatment: Key Lessons • A View from the Field

3. Diabetes-Related Death Rate, 2006Deaths per 100,000 population

4. What causes these Racial/Ethnic Disparitiesin Health? • Social Determinants • Access to Care • Health Care?

5. 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

6. Disparities in Health Care Key Lessons from Unequal Treatment

7. Minorities Face Greater Difficulty in Communicating with Physicians Percent of adults with one or more communication problems* 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 2001 Health Care Quality Survey.

8. Clinical Decisionmaking and Stereotyping • Automatic aspects; groupindividual • “Cognitive Misers”cognitive shortcuts to save resources; principle of “least effort” • Primal->race, gender, age • Activated most when: • Stressed • Under time constraints • Multitasking

9. The Patient Perspective: Unequal TreatmentKaiser Family Foundation Survey, 2000 Percent

10. 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

11. A View from the Field Racial/Ethnic Disparities in Health Care

12. Quality Health Care • Health care should be • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

13. Linking Disparities to Quality • Safe • Minorities have more medical errors with greater clinical consequences • Effective • Minorities received less evidence-based care (diabetes) • Patient-centered • Minorities less likely to provide truly informed consent • Timely • Minorities more likely to wait for same procedure (transplant) • Efficient • More test ordering in ED for minorities due to poor communication • Also • Minorities have more CHF readmissions, ACS admissions, and longer length of stay for the same condition

14. A View from the Field Building Equitable Systems and Incentives • Race/ethnicity data collection • Quality improvement plans and incentives to achieve goals (P4P) Increase Capacity of Health Care Providers • Foster cultural competence of health care providers Empower Patients • Support navigation and educational activities 20/80 Rule: NHDR • Asthma, Diabetes, CVD, CRC Screen, Mental Health New Innovations • Health Information Technology: PHR, EMR, CDM

15. Hospitals: MGHIdentifying and Benchmarking Disparities: • Medical Policy • All QI stratified by race/ethnicity • Unit-Based Staff Quality Rounds • Exploring potential disparities-causing events • Patient Satisfaction • Stratify results by r/e and added questions about respect for culture/race/religion • Nat’l Hosp Qual Measures, HEDIS Measures • Stratifying results by race/ethnicity • Disparities Dashboard • Report routinely to leadership

16. We are including the Core Measures for Heart Attack, Heart Failure and Pneumonia.

17. The MGH Chelsea Diabetes Program Chelsea: Large minority and immigrant community (Hispanic/Latino primarily, but also Bosnian, Somali) about 3 miles from hospital. MGH Chelsea Healthcare Center provides community based care MGH Chelsea Diabetes Program: 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 (1500 visits, 400 routine patients seen) • Group education meeting ADA requirements (150 patients)

18. Decrease in target group HgbA1c 1.5 * * Chelsea Diabetes Management Program began in first quarter of 2006; in 2008 received Diabetes Coalition of MA Programs of Excellence Award

19. Accreditation, Quality Measures, Employer Leverage • NCQA • New efforts in disparities; measures completed public comment • Joint Commission • New disparities/cultural competence accreditation standards 2007, new measures to be implemented in 2010-11 • National Quality Forum • Released cultural competence quality measures • National Business Group on Health • Developed major effort to educate employers about disparities, including making the business case

20. Summary • There is a significant body of evidence that has identified racial/ethnic disparities in health care • Hospitals can play a major role in their elimination through quality improvement and cultural competence • Essential elements include data collection, quality improvement, provider and patient interventions • IOM recommendations will improve the care not only of minorities, but of all Americans