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

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 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; 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

The Patient Perspective: Unequal Treatment Kaiser Family Foundation Survey, 2000 Percent

IOM’s Unequal Treatment 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:

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

* 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  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 Americans More information about our programs can be found at: