The U.S. healthcare system has made some strides in terms of quality but has remained stagnant when it comes to equality. That was the message from the 2010 National Healthcare Quality Report and National Healthcare Disparities Report, companion studies released annually since 2003 by HHS' Agency for Healthcare Research and Quality.
Lacking in equality
AHRQ report shows little change in disparities
According to these latest reports, healthcare quality continued to improve gradually at roughly the same rate—2.3%—seen in recent years. The largest gains were seen in treatment of acute illnesses and injuries, preventive services and immunizations, while measures related to smoking cessation, obesity and substance-abuse counseling stayed flat.
But the racial, ethnic and socio-economic disparities affecting quality and access to care have not changed much at all. Low-income patients receive worse care than their high-income counterparts for about 80% of core measures, AHRQ said in the report. Blacks received lower-quality care than whites for 40% of core measures, and that percentage jumped to 60% for Hispanics.
Dr. Carolyn Clancy, AHRQ's director, called the disparities data disappointing, but she said it shows the urgent need for specific solutions that are tailored to the healthcare needs of individual communities.
“To some extent, there was a hope that if we focused on providing the best care for everyone, that would improve performance for all,” Clancy said. “But what we are seeing is that although that is true, those differences persist.”
The Patient Protection and Affordable Care Act's focus on new models of care delivery and population health may bring some improvements, said Dr. Anne-Marie Audet, vice president of health system quality and efficiency at the New York-based Commonwealth Fund. Successful initiatives start with having a firm grasp on the characteristics of a specific patient population and then crafting interventions based on that knowledge, she said. But that strategy does not work in a fee-for-service world, Audet added.
“You need to be able to identify a patient population's needs, including who needs high-touch care and who needs low-touch, and then you need to decide how to use your resources and workforce to get the best outcomes,” Audet said. “Accountable care organizations are designed to have more of that population-based approach.”
Additionally, new payment models might facilitate a more holistic view of care that takes into account issues such as poverty, health literacy and the need for a diverse healthcare workforce, said Nikki Highsmith, a senior vice president at the Center for Health Care Strategies, a Hamilton, N.J.-based not-for-profit organization that focuses on the healthcare needs of low-income adults and children.
Boston-based Massachusetts General Hospital is working to address healthcare inequality by using a dashboard that gathers quality data and stratifies it based on race and ethnicity. The system, which has been in place for five years, allows the staff to gather community-specific data and create customized strategies to boost performance, said Dr. Joseph Betancourt, director of the hospital's Disparities Solutions Center.
Massachusetts General made the dashboard data public in 2009, and they've used it to design a variety of interventions, including one that improved in-office diabetes testing rates for Hispanic patients and another that addressed low rates of colorectal screening among minority patients.
Betancourt said the healthcare reform law marks the first time disparities were addressed in a significant way in federal legislation. But he also expressed concern that with some lawmakers pushing for the bill's repeal, provisions that address healthcare inequality could be first on the chopping block.
One thing that might help spur more progress is the growing awareness that healthcare disparities have a big effect on the bottom line, he said.
“My sense is that what the early adopters have realized is that if we are inattentive to the root causes of disparities now, we will be ill-equipped to implement healthcare reform,” Betancourt said. “Organizations can have a tendency to table these issues, but they need to be looked at simultaneously with other quality concerns.”
For instance, he said, the healthcare reform law includes future penalties for readmissions, and a recent study published in the Journal of the American Medical Association found higher 30-day readmission rates among black Medicare beneficiaries.
“Clearly we have a lot of good work to do,” said AHRQ's Clancy. “The urgency and the opportunity to ramp up these efforts are there. There's been a lot of work in recent years, and now is the time to accelerate in a big way.”
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