An Organized Process Approach to Reduce Clinical Disparities in Medicare Lawrence Casalino MD, PhD University of Chicago Academy Health Annual Research Meeting, June27, 2005

Three Equations Quality = f(capabilities + incentives) Capabilities = MD capabilities + organizational capabilities Effects of incentives = intended effects + unintended effects

Two Views of Quality Capabilities = MD capabilities + organizational capabilities Individual physician view Organized process view

Individual MD Effort is Not Enough Focus on individual MD knowledge, attitudes, “cultural competence” necessary but far from sufficient Need organized processes in the physician group as well To reduce disparities, need organized processes directed specifically at this goal Organizations as well as individual MDs can be culturally competent

Examples of Organized Processes = “Care Management Processes = CMPs” identify patients who most need care –registries –software to stratify patients communicate with patients outside the traditional office visit; support patients in managing own illness –telephone, , mail, Internet –group visits

Examples of CMPs (II) Support MD and nurse decision- making –via phone and/or biometric device frequent contact with patients –via reminders and “decision-support” - e.g. re medication prescribing - at the point of care

Examples of CMPs (III) provide feedback on performance –to individual physicians and to physician groups and to hospitals and health plans –risk-adjusted for race and/or socioeconomic status?

CMPs and Disparities CMPs may increase disparities if minorities are less likely to have access to them or less likely to understand them CMPs could reduce disparities if adapted to minority patients as necessary

Quality Incentives Could Increase Disparities Effects of incentives = intended effects + unintended effects

Unintended Effects of Quality Incentives? (I) If physicians anticipate that quality scores will be lower for minority patients, may avoid such patients If wealthier physician groups achieve higher quality scores, they will get richer, while the poor groups (likely to be serving minorities) get poorer

Unintended Effects of Quality Incentives? (II) Minority patients less likely to be able to: –access and understand public reporting of quality measures –act on this understanding (e.g. by switching physicians - high quality physicians may not be nearby)

What Might CMS Do? (I) Increase the capabilities of MDs and MD groups to  quality and  disparities –influence medical education re cultural competence and CMPs? –encourage development of clinical IT capabilities? –carefully designed rewards for quality will encourage MD groups to invest in increasing their capabilities

CMS and Incentives must be risk-adjusted and ? adjusted for race and/or SE status, even for process measures reward both absolute quality score and percentage improvement ? rewards for reducing disparities