Use financial incentives to reduce racial and ethnic disparities in healthcare

Thirteen years ago, I co-authored an Institute of Medicine report documenting that racial and ethnic minority patients routinely receive lower-quality care than their white counterparts, regardless of income or insurance status.

While the report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” received a lot of attention in 2002, it is sadly still relevant today, given the persistence of the disparities it documents.

As the Agency for Healthcare Research and Quality recently pointed out, even though we're progressing on improving healthcare quality, we're not so hot on improving equity. That's not to say there haven't been efforts to narrow the divide. In 2010, the Affordable Care Act authors specifically included provisions to reduce healthcare disparities and increase coverage options for vulnerable populations. And at the Robert Wood Johnson Foundation, eliminating healthcare disparities is central to our vision of building a nationwide culture of health, where all Americans have the opportunity to live their healthiest life possible.

And we can point to real progress creating the resources and knowledge base to address disparities. Through programs such as Finding Answers: Disparities Research for Change—a decade-long effort funded by the foundation to seek and evaluate strategies for eliminating disparities—we now know what does and doesn't work.

Here's what doesn't work: You can't get a handle on the effectiveness of quality-improvement activities aimed at improving equity if you don't track care by patient race and ethnicity.

All too often, these initiatives are focused solely on improving overall health, and ignore the critical need to close the gap between white and minority patients.

Here's what works: linking quality and equity. It's important to note the connection between the two, because equal access can still result in unequal care. As Finding Answers has shown, equity is a cross-cutting component of quality. Over the past decade, participating clinics and hospitals have identified steps providers can take to link quality and equity, from collecting basic patient data to measure disparities to implementing culturally appropriate approaches to patient care. Finding Answers has included this and other information in its Roadmap to Reduce Disparities, an evidence-based framework that healthcare organizations, technical-assistance providers and policymakers can follow to address disparities.

Despite the acknowledgement and data showing that disparities exist, many healthcare executives continue to falsely assume that disparities do not exist at their institutions, and therefore, they are not actively working to eliminate them. One study found that, while 88% of physicians believe that racial and ethnic disparities in diabetes care existed, only 40% believed such disparities existed in their own practices.

If providers narrowed their approach and examined performance data classified by race, ethnicity and even language, they would better understand the type and extremity of disparities within their practices, and could appropriately and actively address them. Simply put, providers can correctly identify disparities by first understanding how they performed on a given quality measure for each racial group, and then comparing their performance in one group against how they fared with another.

That's why we need to explore financial incentives as a tool to help the system take that step and address disparities. As we move forward and prepare for new reimbursement systems, emphasizing value of care over volume, many employers and insurers are pursuing providers who are dedicated to promoting equity in their networks. But sometimes it's tricky to connect all the dots.

Starting this fall, the Finding Answers team is transitioning its work to a new program focused on reducing disparities through payment and delivery-system reforms. This work will explore whether and how payment system changes might make it easier for providers to make eliminating disparities a priority.

We're hopeful that by making a business case for equity, and rolling it into payment, providers will be motivated to check for disparities in their care and engage in quality-improvement efforts to reduce them.

Attacking disparities from every angle—including the pocketbook—is the only way we'll ensure that race and ethnicity do not dictate the care patients receive. It's a crucial part of working together to build a culture of health that enables all in our diverse society to lead healthier lives, now and for generations to come.