Health reform could hurt minority groups if not done right

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes that equity should be an important component of health reform.

Health care reform could actually hurt minority groups unless Congress makes some fixes. Without an explicit focus on equity, reform could leave millions of these Americans behind.

The goal of the reform bills in the House and Senate is to dramatically expand access to coverage, including for minority groups, which are traditionally under-insured. But the bills also envision measuring doctors’ and hospitals’ results and paying them based on how well they perform. And while that is a laudable goal, it could also hurt minority groups if not done right. If, for instance, we start measuring and penalizing hospitals depending on how many patients need to be admitted again, hospitals could have incentives to turn away the poorest and sickest patients; who tend to also be people of color. And safety net hospitals that underperform, already overburdened and underfunded, would be further deprived of resources.

The issue looms large given that racial and ethnic minority groups will be in the majority in the U.S by 2050. They already account for half the uninsured, are poorer in health, suffer more disease and are more likely to get inferior care. There are also equity implications in the transformation taking place in provider reimbursement as the notion gains ground that we need to systematically and rigorously examine how well our doctors and hospitals perform and pay them accordingly.  Especially important, in the interest of attaining quality care for all patients, is measuring how well the system treats minority groups.

There is growing recognition on Capitol Hill that the equity issue merits attention – and an increasing understanding that there are deliberate steps we can take to reduce disparities. For instance, Congress last year passed the Medicare Improvements for Patients and Providers Act, which promotes more measurement, including how minority groups are faring. And the American Recovery and Reinvestment Act of 2009 brought more of the same, including using computers and other technology to keep track of how patients are treated, including minorities. Meanwhile, a Robert Wood Johnson Foundation program called Expecting Success is one of several national initiatives that have begun to successfully tackle the disparities issue. Expecting Success worked with 10 hospitals to measurably improve the care of blacks and Hispanics by using evidenced-based guidelines for care. These hospitals showed disparities can be eliminated, and the national conversation about the quality of our health care must include a discussion of how to build on this and other efforts.

Here are four recommendations that Lea Nolan, my colleague at the Department of Health Policy in the School of Public Health and Health Services at the George Washington University, and I recently proposed in an article in the New England Journal of Medicine.

First, it is essential that insurance plans meet rigorous quality benchmarks for the flood of newly insured minorities that health care reform may bring. These plans need to be prepared to meet the needs of patients for which disparities in health status and quality and outcomes will be critical.

Second, we need to know how these people are doing under the new system. All health plans and providers regulated by the federal government need to start reporting race and ethnicity as they report how their patients fared under their care. After all, the federal government for almost 20 years has made mortgage lenders disclose this information – why not hospitals?

Third, we have to make it worthwhile for hospitals and doctors to do better regarding minority groups. For openers, we should incentivize providers to collect and report data stratified by racial and ethnic group, building on exiting programs that pay for reporting. We should also ensure that pay-for-performance payments reward improvements, not absolute performance, to support providers that care for the largest numbers of minority patients and hence have a higher hill to climb.

Fourth, we may as well get used to the fact that reversing a legacy of inequality in medicine is going to cost money and require a real transformation. Providers who treat a disproportionately large number of minority patients often do not measure at the top level of performance. Beyond new technology, we need to seriously invest in the safety net hospitals and clinics where these patients tend to seek care.

We have the knowledge to tackle the issues of racial and ethnic disparities in health care. Congress has a unique opportunity to put it to work. Done right, health care reform can make great strides in leveling the field and achieving quality care for all.