Current assessments of quality of care do not recognize disparities in health care quality related to socioeconomic status (SES) and race/ethnicity. In fact, considerable variation in care delivery within a health care plan can be masked because existing quality measures do not capture critical disparities, according to the authors of a recent commentary. For instance, under current National Committee for Quality Assurance (NCQA) reporting requirements, childhood immunizations or low birthweight rates from HMOs with affluent members may be compared with those from plans with predominantly working poor members, even though lower SES typically lowers performance ratings.
Similarly, a hospital can achieve acclaim for the success of its cardiac surgery program, yet escape notice for providing reduced access to effective treatments for minorities. These disparities signal an area potentially ripe for quality improvement, note Carolyn M. Clancy, M.D., of the Agency for Healthcare Research and Quality, Peter Franks, M.D., of the University of Rochester School of Medicine and Dentistry, and their colleagues. Their work was supported by the Agency for Healthcare Research and Quality (HS09963).
The authors outline five proposals for integrating health care disparities into mainstream quality assurance. They propose collecting relevant and reliable data to address disparities and stratifying performance measures within existing quality measures by SES and race/ethnicity. For example, they recommend that managed care organizations not simply report overall rates of Pap smear screening among eligible women but also report separate rates by SES and race/ethnicity.
The NCQA and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) can play vital roles by requiring the inclusion of SES and/or race/ethnicity in performance reports. The authors also propose linking reimbursement to the SES and racial/ethnic composition of the enrolled population. They suggest, for instance, that the Health Care Financing Administration expand reimbursement rates to include not only adjustment for case mix, but also SES and race/ethnicity to compensate plans for enrolling patients with greater morbidity not fully captured by case-mix adjustment. However, this strategy does not substitute for providing quality reports that are stratified by SES and/or race/ethnicity.
For more information, see "Inequality in quality: Addressing socioeconomic, racial, and ethnic disparities in health care," by Kevin Fiscella, M.D., M.P.H., Dr. Franks, Marthe R. Gold, M.D., M.P.H., and Dr. Clancy, in the May 17, 2000 Journal of the American Medical Association 283, pp. 2579-2584.
Reprints (AHRQ Publication No. 00-R030) are available from the AHRQ Publications Clearinghouse.