Individual Physicians or Organized Processes: How Can Disparities in Clinical Care Be Reduced?

This paper makes four basic arguments:

1. The extent to which racial and ethnic disparities are reduced is a function of the incentives and the capabilities of a physician or organization to reduce them
2. Increasing physicians’ cultural competence and their use of evidence-based guidelines will be useful, but far from sufficient, to reduce disparities
3. Many types of efforts to improve quality are likely to increase rather than reduce disparities, although they may increase the absolute level of quality of care received by minorities.To reduce disparities, targeted, as well as general, efforts at quality improvement will have to be made.
4. Medicare is making some important efforts to improve quality and reduce disparities, but it can, and should, do much more.

Based on these arguments, the paper makes the following recommendations:

1. Medicare should pay physicians differentially based on the quality of care that they provide.Quality measurements on which pay-for-performance are based should be carefully risk adjusted and statistically valid and reliable.Medicare should reward improvement in quality as well as its absolute level.

2. Medicare should seek to increase the capabilities of medical groups to improve quality and reduce disparities.

3. Medicare may also be able to increase quality and reduce disparities by improving communication with patients, giving incentives to patients for healthy behaviors, and working through health plans.

This paper was commissioned by the NASI Study Panel on Medicare and Racial and Ethnic Disparities.