Disparities in Health and in Health Care

April 2008

What may be most notable about the disparate care individuals receive in this country is the breadth and complexity of the problem, starting with the lack of a common definition of "health disparity."1 Research shows that we have an enhanced ability to measure and track the quality of care among vulnerable subgroups of the population, however, much work is needed to develop solutions to eliminate the current inequalities evident at the individual/community level, provider level, and organization level.

There is no one determinant of disparate outcomes within the health care system. Education, culture, environment, employment, socio-economic status, politics, access barriers, providers' cultural competency and numerous other factors contribute to a growing health divide among various populations in this country.2 Yet, racial and ethnic minorities are disproportionately burdened with inadequate health care and poor health status.

Knowing how to shape and where to target interventions is challenging. One example of this challenge was captured in a 2006 report from the Institute of Medicine titled, Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business.4 The IOM was charged with assessing the congressionally mandated establishment of the NIH National Center on Minority Health and Health Disparities and its strategic plan to assess the poor health status of minorities, low income and rural residents. The IOM concluded that while the NIH effort was a start, much more would need to be done to place greater focus on health disparities as a research entity, to achieve greater trans-NIH coordination, and to strengthen its strategic plan by promoting "more integration of research on the multifactorial nature of health disparities."5

Individual and Community Level

Before policymakers can develop solutions to eliminate current disparities, it is important to understand the underlying dynamics at the individual and community level. As noted in work by HCFO researcher Kevin Fiscella, M.D., University of Rochester, the fact that health care utilization differs by race and ethnicity suggests that cultural beliefs, attitudes, and norms may be influencing these disparities. In a new study funded by the Kaiser Family Foundation, researchers found wide disparities in health coverage among Asian Americans, Native Hawaiians and Pacific Islanders - a reminder that in addressing equity in healthcare, community-level analyses are critical.6

Provider Level

Cultural competency of health care providers is one of the critical factors at issue in determining how best to address the racial and ethnic divide. In HCFO-funded research, Mark Doescher, M.D., and colleagues at the University of Washington determined that minority patients have less positive perceptions of their physicians than whites.7 Researchers at Vanderbilt recently cautioned that insofar as African Americans are less likely to receive colonoscopy screening compared with whites who have affected relatives, there needs to be increased efforts on the part of providers to collect a complete family history in order to better identify and manage underserved populations at increased risk for colon cancer.8

Organization Level

To the extent there continues to be unequal care delivery at the organizational level, disparities will persist. Recently, HCFO funded Ashish Jha, M.D., Harvard University School of Public Health, to examine the impact of financial incentives on quality in hospitals that care for minority and underserved populations. In a different study, HCFO researcher Joel Weissman, Ph.D., Massachusetts General Hospital Institute for Health Policy, is focusing on measures of quality and will explore the extent to which care varies by race, ethnicity, or by insurance status within and across hospitals.

Taking a broader view, beyond hospitals, HCFO researcher Marsha Gold, Sc.D., Mathematica Policy Research, Inc., is currently examining the capacity of states to link overall improvements in public health to reduce disparities in health status across diverse subgroups of the population.9

Ensuring that there is adequate information to make informed decisions is an important step toward eradicating disparities. The March/April 2008 issue of Health Affairs is devoted entirely to health disparities10 and was sponsored by the Robert Wood Johnson Foundation.11  Recently, AcademyHealth Board member, Anne Beal, M.D., The Commonwealth Fund, introduced a Chartbook created by the Fund, which is a resource for a variety of audiences seeking to understand the dynamics of disparities and develop solutions.12  In a series of interactive webcasts, the Kaiser Family Foundation also addressed a range of topics in health disparities.13  As part of this effort, Kaiser compiled a compendium of federal legislative initiatives introduced in the current Congress to address racial and ethnic disparities.14  

Whatever the mechanism to reduce inequality in our health care system, it is incumbent on policymakers to develop solutions which will balance the delivery of health services, and improve the health of vulnerable populations and the health status of the country as a whole.

The following selected grants from HCFO's portfolio may help inform policymakers about disparities in health and health care.  For other HCFO grants see www.hcfo.net.

Title: The Impact of Pay-for-Performance on Hospitals that Care for Minorities and the Poor
Institution: Harvard University School of Public Health
Principal Investigator: Ashish Jha, M.D.
Grant Duration: February 2008 - July 2008

The researchers will examine the impact of financial incentives to improve quality on hospitals that care for minority or other underserved populations. The Centers for Medicare and Medicaid Services have implemented pay for performance (P4P) demonstrations, and are considering implementing P4P nationally. However, the impact of P4P has not been widely evaluated. Hospitals that care for underserved populations may have greater potential for quality improvement; conversely these facilities lack the tools and resources to improve quality and compete for the additional resources. The researchers will examine changes in quality for hospitals in the Medicare Premier P4P Demonstration that serve disadvantaged populations (minority and poor); these changes will be compared with changes in hospitals in the demonstration that do not serve disadvantaged populations and with hospitals that serve disadvantaged hospitals not in the demonstration (and not subject to P4P). The objective of the project is to provide more information about the impact of P4P on hospitals that serve disadvantaged populations, and help policymakers to design incentive systems that encourage higher quality care without disproportionately harming hospitals that care for these populations.

Title: Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
Institution: NORC
Principal Investigator: Claudia Schur, Ph.D.
Grant Duration: January 2008 - March 2009

The researchers will examine the public health needs of culturally and linguistically diverse populations. Specifically, they will develop detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by local health departments (LHDs). They will then use these profiles to analyze the relationships between population characteristics and existing public health capacity and to identify and survey select communities for more in-depth information about serving these populations. They will seek answers to the following research questions: 1) How do jurisdictions with LHDs compare in terms of the composition of the population served? To what extent do communities include substantial numbers of racial/ethnic minorities, immigrants, and/or persons who speak a language other than English? 2) Does the structure and capacities of LHDs vary with respect to the multicultural profile of the populations they serve? How do LHD resources and activities correspond to local community characteristics? 3) What are the specific strategies that LHDs engage in to meet the needs of diverse populations? What types of strategies appear to be most successful? Are community partnerships used either for training purposes or for the delivery of culturally appropriate services? 4) What obstacles appear to be most difficult to overcome in serving different types of population subgroups? Which types of services are most difficult to deliver? What characteristics or combinations of characteristics of communities and LHDs create the most substantial obstacles? The objective of this project is to develop policy recommendations for implementation of promising strategies to better serve diverse populations.

Title: Financing American Indian Health Care: Impacts and Options for Improving Access and Quality of Care
Institution: Sanford Research/University of South Dakota
Principal Investigator: Kathryn Langwell
Grant Duration: September 2007 - August 2008

The researchers will examine health care access and quality of care for American Indians who receive care through the Indian Health Service (IHS). In particular, they will: 1) determine the resources (national and regional per capita spending) available for health care for this population from 2000 to 2005; 2) assess service priorities and the mechanisms for explicit and implicit rationing of care; 3) analyze the impact of priorities and rationing mechanisms on access to care, availability of services, quality, and outcomes; and 4) develop options for improving access and quality for American Indian heath care and analyze the feasibility and costs of these options. The objective of the project is to contribute to the understanding of the impact of current financing and organization of the Indian Health Service on access and quality and the contribution of these factors to the health disparities experienced by this population.

Title: Examining the Quality of Hospital Care and Simulating the Impact of Several Pay-for-Performance Scoring Methods on Hospital Rankings
Institution: Massachusetts General Hospital Institute for Health Policy
Principal Investigator: Joel S. Weissman, Ph.D./Lisa Iezzoni, Ph.D.
Grant Duration: March 2007 - August 2008

The researchers will examine the quality of hospital care. Using patient-level data from a large sample of hospitals collected by the Hospital Quality Alliance (HQA), they will estimate the proportion of patients receiving recommended care, create new measures of patient care quality, and simulate the impact of several pay-for-performance (P4P) scoring methods on hospital rankings. They will also examine the extent to which care varies by race, ethnicity, or insurance status within and across hospitals. The objective of the study is to assist CMS, other public and private payers, and accrediting organizations in developing strategies to improve hospital performance measurement and payment methods, and, ultimately, the quality of patient care.

Title: Incorporating Disparities into State Strategies to Monitor and Improve Health Status
Institution: Mathematica Policy Research Inc.
Principal Investigator: Marsha Gold, Sc.D.
Grant Duration: January 2007 - March 2008

The researchers will examine state capacity to develop the 10 leading indicators defined in Healthy People 2010 overall and by geographic group. In particular, they will study: 1) the strengths and weaknesses of data available within states to adequately assess the health of a population that includes diverse groups; and 2) the organizational, political, and other forces that promote or impede use of such data to intervene in ways that improve the health of the state's population. The three part study includes: 1) an inventory of state practices with respect to available data on leading indicators; 2) case studies of four states to learn about how the indicators and disparities in the indicators across subgroups are viewed in developing initiatives to improve public health; and 3) a dissemination plan for translating information in ways that would be useful to diverse audiences. The objective of this project is to further the vision articulated in HealthyPeople 2010, setting health goals that explicitly link overall improvements in public health to reduced disparities in health status across diverse subgroups of the population.

Title: Public Health Funding and Population Health
Institution: University of Washington
Principal Investigator: David E. Grembowski, Ph.D.
Grant Duration: January 2007 - June 2008

The researchers will examine the relationship between local health department expenditures and county-level disparities in mortality and infant mortality rates for Black and White racial/ethnic groups. They will also estimate whether changes in expenditures are associated with changes in those rates over time. The objective of this project is to inform the debate about the level of resources that should be allocated to public health systems rather than to medical care or other determinants of population health.

Title: How Managed Care Growth Has Affected Health Departments' and Physicians' Ability to Provide Indigent Care
Institution: University of Pittsburgh
Principal Investigator: Christopher Keane, Sc.D.
Grant Duration: January 2002 - March 2003

To what extent have increases in managed care affected the provision of care for the uninsured by local health departments (LHDs) and physicians? Researchers at the University of Pittsburgh are analyzing whether managed care has: 1) diverted Medicaid revenues away from LHDs, reducing their cross-subsidization and provision of care for the uninsured; 2) decreased the Medicaid revenue of doctors employed by organizations with a mission to serve the uninsured, and decreased these physicians' charity care; 3) decreased physicians' autonomy, leading to decreased charity care; 4) decreased LHDs' ability to ensure access; and 5) reduced trust in medical providers among the uninsured, leading to lower utilization. They are using two rounds of the CTS Household and Physician Surveys, InterStudy data, American Hospital Association data, the Area Resource File, and a representative survey of 240 LHDs in his analyses. The project is exploring why high levels of managed care penetration are associated with reduced access among the uninsured, and is developing policy implications from the study's findings, describing unforeseen consequences of recent policies, and assessing implications for future policy.

Title: Racial and Socioeconomic Disparities in Health Care Among the Insured
Institution: University of Rochester
Principal Investigator: Kevin Fiscella, M.D.
Grant Duration: January 2000 - December 2000

What is the effect of managed care market penetration on socioeconomic and racial/ethnic disparities in health care?  Researchers at the University of Rochester hypothesized that, given managed care's assumption of responsibility for the health care of populations (rather than specific individuals), managed care penetration may help alleviate disparities in health care access and quality between different socioeconomic and racial/ethnic populations.  Among their hypotheses was that enrollment in an HMO will result in lower access, utilization and satisfaction, but higher overall disease prevention compliance. In addition to the CTS Household Survey, the researchers used market data from the Area Resource File in their analyses.  The study had three specific objectives: 1) to examine racial/ethnic and socioeconomic disparities in health care access, utilization, preventative care, and satisfaction among insured populations; 2) to compare disparities in health care by socioeconomic and racial/ethnic status among person enrolled in HMOs with similar individuals covered through indemnity insurance; and 3) to examine disparities in health care access, quality, and satisfaction among HMO enrollees of different racial/ethnic groups based on HMO market penetration, patient choice, and duration of enrollment. 

Title: Uninsured in American: Individual and Community Factors
Institution: University of Washington
Principal Investigator: Barry Saver, M.D.
Grant Duration: March 1999 - February 2001

Does an individual's community have an impact on the decision to purchase health insurance in the private market? A team of University of Washington researchers examined whether community-level characteristics, such as unequal income distribution, segregation in housing, and availability of safety net services, affect the decision to purchase private health insurance, as well as access to care of uninsured persons. Access was measured using estimates of services available to uninsured or vulnerable populations in the community (e.g., the community's "safety net"), as well as whether the availability of safety net services influences low-income individuals' and families' decisions about whether or not to purchase individual insurance. In addition, the researchers estimated the probability of purchasing individual insurance, delaying or not obtaining care, utilizing outpatient services, and having a regular source of care. They used the Community Tracking Study Household Survey, along with data from HCFA, the American Hospital Association, the Census Bureau, the Area Resource File, the Urban Institute's "Assessing the New Federalism" project, and George Washington University data on the percent of medically underserved persons served by federal and state funds or programs. The project's objectives were to: 1) assess how individual, community, and state-level factors affect the decision to remain uninsured or to purchase individual health insurance and whether those factors explain lower rates of individual insurance purchased by minorities; and 2) describe access problems experienced by the uninsured. 

Title: Access to Care Among Hispanics: Implications for Understanding Community Variation
Institution: Project HOPE
Principal Investigator: Claudia Schur, Ph.D.
Grant Duration: March 1999 - November 2000

Do rates of access to health care differ between Hispanics and non-Hispanics, and if so, how much of that difference can be accounted for by the measurement tools used? Researchers at Project HOPE examined how access to health care differs between Hispanic and non-Hispanic populations, as well as between sub-groups within the Hispanic population. They developed a measure of access based on the use of services relative to health status. This approach was designed to be less dependent on respondent perceptions than traditional approaches. In addition, they analyzed variation in access across communities, for both Hispanics and non-Hispanics, comparing the results using this newly-developed measurement method, and those using existing measurement tools such as number of physician visits, hospitalizations, and inability to obtain care. The analysis was done using hierarchical modeling of data from the Community Tracking Study Household Survey, which served to reduce random variation across communities and allowed researchers to draw more credible inferences about the role of community and personal characteristics relative to access. Finally, they linked the Tracking data to data from the U.S. Census in order to examine characteristics that may affect access to care in communities where Hispanics live. The objective of this study was to not only understand access issues faced by Hispanics, but to better understand the extent to which apparent differences in access, obtained by traditional measurement methods, are a result of measurement technique as opposed to actual difficulties faced by the populations.

1 Carter-Pokras, O., and C., Baquet. "What is a 'Health Disparity?'" Public Health Reports, Vol. 117, September/October 2002, pp:426-34. Also see www.nempha.org/What%20is%20a%20health%20disparity.pdf ; "Healthy People 2010," for example, defines "health disparity" as "differences that occur by gender, race or ethnicity, education or income, disability, living in rural localities or sexual orientation."
2 In February 2008, the Robert Wood Johnson Foundation announced the formation of a new Commission to Build a Healthier America. The Commission will explore the varying determinants of health and identify innovative ways to improve the health of all individuals. Also see  www.rwjf.org/newsroom/newsreleasesdetail.jsp?productid=26672&typeid=160
3 See for example, the Agency for Healthcare Research and Quality's 2007 National Healthcare Disparities Report (NHDR) www.ahrq.gov/qual/qrdr07.htm, as well as research funded by AHRQ on minority health. www.ahrq.gov/browse/minorra.htm ; See also, Unnatural Causes: is inequality making us sick?, a 7-part documentary series exploring racial and socioeconomic inequalities in health. www.unnaturalcauses.org/
4 Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business. Ed. Thomson, G., et al. Committee on the Review of the NIH's Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities, Washington, DC: The National Academies Press, 2006. Also see http://books.nap.edu/openbook.php?record_id=11602&page=R1
5 Ibid.
6 "Health Coverage and Access to Care Among Asian Americans, Native Hawaiians and Pacific Islanders," Kaiser Family Foundation, April 1, 2008. Also see http://www.kff.org/minorityhealth/7745.cfm
7 Doescher, M.P., et al., "Racial and Ethnic Disparities in Perceptions in Physician Style and Trust," Archives of Family Medicine, Vol. 9, No. 10, November/December 2000.
8 Murff, H.J. "Colonoscopy Screening in African Americans and Whites with Affected First-degree Relatives," Archives of Internal Medicine, Vol. 168, No. 6, March, 24, 2008, pp:625-31.
9 In related work funded by HCFO, Christopher Keane and colleagues at the University of Pittsburgh explored local health departments' mission to the uninsured and other vulnerable populations. Directors of local health departments (LHDs) who were surveyed noted that even assuming universal insurance, LHDs offer unique services, particularly for culturally diverse populations, the homeless, and immigrants. Keane, C., et al. "Local Health Departments' Mission to the Uninsured," Journal of Public Health Policy, Vol. 24, No. 2, 2003.
10 "Black, Latino Children More Than 12 Times As Likely As White Children To Both Be Poor, Live In Poor Neighborhoods, Which May Negatively Affect Their Health," Press Release, Health Affairs, March 11, 2008. Also see www.healthaffairs.org/press/marapr0801.htm
11 "Select Articles from the RWJF-Sponsored Issue of Health Affairs 'Disparities in Health: Expanding the Focus,'" Robert Wood Johnson Foundation, 2008. Also see www.rwjf.org/pr/product.jsp?id=27151
12 Mead, H., et al. "Racial and Ethnic Disparities in U.S. Health Care: A Chartbook," Commonwealth Fund, Vol. 27, March 13, 2008. Also see www.commonwealthfund.org/publications/publications_show.htm?doc_id=672908 ; Beal, A. "Addressing Racial and Ethnic Health Disparities by Improving Health Care Quality," Commonwealth Fund, March 31, 2008.  www.commonwealthfund.org/aboutus/aboutus_show.htm?doc_id=675762
13 "Today's Topics In Health Disparities," KaiserNetwork.org, Kaiser Family Foundation, March 12, 2008. www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=2041
14 "Key Health Disparities-Focused Legislation Introduced in the 110th Congress," Kaiser Family Foundation, December 14, 2007. www.kff.org/minorityhealth/7724.cfm