Program Goals:

Disparities in health care access and quality of care have been well documented by The Commonwealth Fund and others. The goals of The Commonwealth Fund's Program on Health Care Disparities are to improve the overall quality of health care delivered to low-income and minority Americans, and to eliminate racial and ethnic health disparities. The program builds on efforts to improve quality of care overall in the United States, focusing on safety-net hospitals and ambulatory care providers serving large numbers of low-income and minority patients. The strategies it pursues include:

• identifying opportunities for improving performance of safety-net providers;
• enhancing the capacity of safety-net providers to improve performance; and
• fostering incentives and policies that promote better performance of safety-net providers.

The Program on Health Care Disparities is led by Assistant Vice President Anne C. Beal, M.D., M.P.H.

The Issues:

Previous Commonwealth Fund work focused on reducing health disparities through improved data collection and reporting found that low-quality providers serve disproportionate numbers of minorities. Fund research also helped define and develop standards for cultural competence and initiated clinical interventions targeted at safety-net providers. The program now aims to improve the performance of minority serving safety-net hospitals and ambulatory care providers in order to reduce disparities in access to high quality care.

Recent Projects:

Understanding Disparities While there is broad consensus regarding the existence of racial and ethnic disparities in health care, there is less agreement about the root causes. Using data from the 2004–05 Community Tracking Study Physician Survey, James D. Reschovsky, Ph.D., and Ann S. O'Malley, M.D., M.P.H., senior health researchers at the Center for Studying Health System Change, examined how the socioeconomic and insurance composition of a provider's patient base contributes to racial disparities. They found that primary care physicians who treat a disproportionate share of black and Latino patients provide more charity care, see more patients, depend more heavily on low-paying Medicaid, and earn lower incomes than physicians with largely white patient populations. In "Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?" (Health Affairs Web Exclusive, Apr. 22, 2008), the they concluded that such payment constraints help explain why physicians who treat large numbers of minority patients report more problems delivering high-quality care than other physicians.

Quality of Care in Hospitals. Research has shown that minority patients tend to see primary care physicians who have less clinical training, see specialists whose patients have poorer clinical outcomes, and seek care at lower-performing hospitals than do white patients. However, a Commonwealth Fund-supported study led by Darrell J. Gaskin, Ph.D., of the University of Maryland and published in Health Affairs finds that when minority and white patients seek care at the same hospital, they receive the same standard of care. These results highlight a fundamental rule: minority patients receive the best care when they are treated in hospitals that deliver the highest quality care. Thus, eliminating disparities may require getting minority patients to receive care in higher performing, rather than underperforming hospitals.

Medical Homes Address Disparities in Access. Findings from "Closing the Divide How Medical Homes Promote Equity in Health Care" based on findings from The Commonwealth Fund 2006 Health Care Quality, showed that racial and ethnic disparities are not immutable. Indeed, the survey found that disparities in access to and quality of care largely disappear when adults have a medical home, insurance coverage, and access to high-quality services and systems of care. systems, in the form of patient reminders, also improve the quality of care for vulnerable patients by promoting higher rates of routine preventive screening. This report was recently cited by two experts during June 10, 2008 testimony to House Ways and Means Health Subcommittee, and has also been cited in draft legislation.

Future Directions:

The Program on Health Care Disparities is interested in funding the following types of projects:

1. Assessments of the current level of performance among minority-serving safety-net providers, and factors associated with high performance in terms of quality of case, patient experiences, and efficiency.
2. Evaluations of innovative models and practices that lead to high performance among minority-serving safety-net hospitals and ambulatory care providers.
3. Assessments of the impact of current payment policies, particularly through Medicaid and Medicare, on safety-net provider performance.
4. Evaluations of health reform and its impact on safety-net provider performance.

For example, to improve performance, the program is supporting Alicia Fernandez, M.D., and Hilary Seligman, M.D., M.S., of the University of California, in their evaluation of a Fund-supported survey instrument—the Patient Assessments of Cultural Competency. This project will expand the scope of a study of diabetes patients at large safety-net hospitals in San Francisco and Chicago. The investigators aim to determine how these patients' diabetes outcomes are affected by patient care experiences and cultural competency in health care delivery. The Russell Sage Foundation will cofund the project.

In another project, Jordan Peugh, M.A., of Harris Interactive will conduct a national survey of CEOs at 1,078 federally qualified health care centers—important providers of care to low-income, uninsured, and minority patient populations—to examine the extent to which their organizations possess the systems and capacity needed to achieve high performance. The survey will focus on medical home structures, engagement in quality improvement activities, and workforce capacity. To investigate the association between clinical performance and organizational measures of high performance, the survey data will be linked to the Uniform Data System used by the Bureau of Primary Health Care.

Linda Cummings, Ph.D., and colleagues from The National Public Health and Hospital Institute, will examine emergency department (ED) throughput in public hospitals—that is, how efficiently patients can be seen, cared for, and appropriately discharged. The team will identify safety-net hospitals that have eased ED overcrowding and improved patient flow. After analyzing the strategies used by the high-performers, they will develop an educational program for 15 public safety-net hospitals that are working to improve ED throughput. Working collaboratively, these facilities will then develop initiatives to increase their efficiency and ability to provide high-quality, efficient emergency care.

Another study, led by Sara Singer, M.B.A., Ph.D., and Nancy Morgan Kane, M.B.A., D.B.A., of Harvard College will identify governance practices and organizational characteristics (such as ownership or affiliation with a Medicaid managed care plan or primary care clinics) of top safety-net hospitals. They will identify practices that lower-performing hospitals could adopt to raise their financial performance and improve quality of care. To do this, project staff will analyze audited financial statements and standardized quality measures, conduct site visits and interviews, and prepare six case studies that feature the practices of high-performing safety-net hospitals.

Romana Hasnain-Wynia, Ph.D., and colleagues from the Health Research and Educational Trust, will conduct the first national study of quality in safety-net hospitals, using national data provided by the Hospital Quality Alliance and the American Hospital Association. The project investigators will focus on the treatment provided to patients admitted with myocardial infarction, congestive heart failure, and community-acquired pneumonia. As part of the study, the project team will survey leaders of safety-net hospitals to determine the extent to which their institutions possess organizational systems and capacity, such as electronic health record systems, needed to engage in quality improvement activities. Based on these findings, the investigators will recommend steps that safety-net hospitals can take to achieve higher performance.

Federally funded community health centers (CHCs) are an integral part of the health care safety net for disadvantaged communities. Deborah Gurewich, Ph.D., and Donald S. Shepard, Ph.D., of Brandeis University, will determine the extent to which health centers in three states with large low-income, minority populations (California, Massachusetts, and Texas) provide cost-effective care, identify health centers that provide high-quality care at reasonable costs, and pinpoint the factors that contribute to the success of these high-performing community health centers. The Texas Association of Community Health Centers will provide cofunding.

To apply for a grant from the Program on Health Care Disparities, visit the Applicant and Grantee Resources page.