New England Journal of Medicine - Leveling the Field — Ensuring Equity through National Health Care Reform lyrics

Congress is currently considering health care reform proposals that have implications for ensuring equity for minority patients. Both the House bill, the Affordable Health Care for America Act, and the Senate bill, the Patient Protection and Affordable Care Act, propose the development and implementation of improved quality measures and the collection and an*lysis of data on race, ethnic group, and language as part of efforts to reduce disparities. However, these proposals apply only to federally funded programs (Medicare, Medicaid, and the Children's Health Insurance Program, as well as any new public insurance plan) and the health plans that contract with them. In addition, other elements of these proposals could have unintended consequences that would make it harder for minority patients to obtain the best health care. The bills would accelerate pay-for-performance and transparency programs that are designed to promote quality improvement, but without thoughtful design, such programs could boomerang: doctors, hospitals, or health plans could discover that it is in their interest to avoid high-risk patients (who are often members of minority groups) whose outcomes could adversely affect their performance ratings. If decreased rates of rehospitalization were a performance goal, for instance, providers might wish to avoid poor, sick minority patients who are likely to lack access to good primary care. Public hospitals and clinics, which already have inadequate resources, could also face funding cuts if the quality of their care did not reach certain thresholds; such cuts would further undermine quality. Reform should include incentives for improvement, not just penalties for poor performance. Health care reform offers an opportunity to address disparities productively, but four things will need to happen. First, it is essential that newly covered populations be enrolled in health plans that meet rigorous, nationally set quality benchmarks. Because so many uninsured people are members of minority groups, expanding coverage will mean reducing disparities in coverage. But it will also require substantial subsidies, given the low incomes of so many of those who are uninsured. Denying insurance subsidies to certain groups, such as undocumented immigrants, will serve only to maintain disparities. And since millions of minority patients may be brought into the health care system, it is important to ensure that health plans are prepared to meet their needs. Disparities in health status and outcomes will probably be even more apparent in newly covered populations, and these populations deserve equitable, effective, and timely care. Second, we need to understand who our patients are and the quality of care they receive. All health plans and providers that are regulated by the federal government or are direct or indirect beneficiaries of public subsidies should be required to collect data on patients' race, ethnic group, and language in a uniform fashion, as recently recommended by the Institute of Medicine. There is a precedent for such a requirement: since 1990, almost all entities that give home loans in the United States have had to report applicants' race. Third, meaningful incentives should be implemented to encourage providers and plans to address disparities. For example, physicians and hospitals could be paid to report information on quality that is stratified according to patients' race or ethnic group. This approach would be a logical extension of that used in existing federal programs such as the Reporting Hospital Quality Data for Annual Payment Update program and the Physician Quality Reporting Initiative, which include “pay-for-reporting” incentives. Eventually, the collected data could be made publicly available — although such a move would encounter some opposition. Pay-for-performance programs will have to reward improvement rather than absolute performance, so as not to erode the funding needed for improving care in settings with fewer resources. The Premier Hospital Quality Incentive Demonstration of the Centers for Medicare and Medicaid Services has shown the promise of such an approach. Fourth, substantial investment should be made in the safety net. If we want to improve the care of minority patients, we need to go where they are — federally qualified health centers, public and inner-city hospitals, and a certain segment of physician practices. Providers who treat a disproportionate number of minority patients often do not achieve maximal performance. The American Recovery and Reinvestment Act of 2009 provided funding to health centers and other Medicaid providers to improve health information technology, but a transformation of the safety net must go beyond technology and ensure that these providers implement rigorous interventions such as adherence to clinical guidelines and coordination of care for the chronically ill. Health care reform provides a unique opportunity to reverse a legacy of inequality in health and health care. This chance should not be squandered.