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How Can Physicians Close the Disparity Gap?

 |  By jcantlupe@healthleadersmedia.com  
   May 05, 2011

Joseph R. Betancourt, MD, MPH, recalls when he was 7 years old in the 1970s he helped his Puerto Rican grandmother interpret in English at a doctor's office in New York City.

During her session with the physician, his grandmother seemed pleased and appeared to understand the doctor's intent. Later, she observed, "I'm not sure what the doctor said and I'm not going to do it anyway,'' Betancourt recalled, evoking laughter from his audience last month at an American Hospital Association meeting in Washington D.C.

Betancourt, director of The Disparities Solutions Center and senior scientist for the Institute for Health Policy, and director of multicultural education for Massachusetts General Hospital, noted that some physicians feel if they "speak loudly enough and slowly enough" they are properly communicating to patients. More laughter.

It may be loud, he says, but it's not enough. And, ultimately, it's not funny.

Under healthcare reform, millions of currently uninsured will be become part of the insured, and many will be seeking care in physician offices instead of emergency departments.

At least 50 million Americans were without health insurance in 2009, according to the Census Bureau. About 32 % of Hispanics, 21% African-Americans, 17% Asian, and 15% whites were listed as uninsured, the bureau states.

To make healthcare reform work and more welcoming to the newly insured, it is important that the healthcare system makes significant efforts to overcome racial and ethnic disparities in care. Otherwise, how can we progress?

Yet, as healthcare reform increases reimbursements for quality, with such programs as Accountable Care Organizations, hospitals and physicians aren't moving fast enough to meet the challenges of diversity in their quality improvement programs, says Betancourt.

There are "many sources that contribute to disparities, there is no one suspect; no one solution," Betancourt said at the AHA meeting.

 "Hospitals have so many things to do. The jury has been mixed on it – do we collect race and ethnicity data? There's a lot of devil in the details. If you don't collect it, you certainly aren't going to link it to quality." As the Joint Commission pursues improvement of quality issues, Betancourt says, "you'll have early adopters and progressive (hospitals) to collect racial and ethnicity data, but others will wait until it is either forced upon them or incentivized."

Earlier this week, Betancourt and I talked more about his comments before the AHA. He says it's important that hospitals – and physicians – begin now to address disparity issues if they haven't done so already.

 "From the standpoint of hospitals – it's really critical that they begin to measure quality by race and ethnicity. And to do that they will need to create race and ethnicity data, and that links to the communication piece," Betancourt says. "If you look at race and ethnicity, you can look at where the gaps are and where you might intervene."

"I think what we are seeing now is a sporadic collection of this information," Betancourt adds. "Even those (hospitals) that are collecting race and ethnicity data, for example, few are linking it to quality measurement."

Certainly, there have been many reports over the years, raising the question of disparity issues and what needs to be done, including the Institute of Medicine's report, Unequal Treatment,' are a treasure trove of reports over the years, on the disparity issue.

The Centers for Disease Control and Prevention recently released "Research to Practice: Building Our Understanding," a series of reports that focuses on health communication practices that address topics ranging the most effective ways to communicate with the Hispanic and Latino communities to helping users apply effective evaluation strategies, as my colleague Alexandra Wilson Pecci wrote about last month.

Communication problems are most frequently the cause of serious adverse events, compromised by language barriers, cultural differences, and low health literacy. The result is increased length of stays, Betancourt says.

Because of communication difficulties, providers may tend to order expensive tests such as CT scans for conditions that could otherwise be diagnosed, Betancourt says. Minority populations are more likely to be readmitted for certain chronic conditions such as congestive heart failure than their white counterparts, he adds.
 
Dealing with communication and disparities issues begins at the C-suite, Betancourt says. The Disparities Solutions Center, which Betancourt heads, which is dedicated to development and implementation of to eliminate racial and ethnic disparities, and provides leadership training to do so. The DSC opened in 2005, with initial funding from Massachusetts General Hospital and the Partners Health Care system, and is affiliated with MGH and the Harvard Medical School's department of medicine.  It issued a guide for hospital leaders about disparity issues, such as diabetes management, and highlights practices to address the issues.

 
 "We have a committed program," he says of Massachusetts General Hospital. " We have a guilty-'til-proven-innocent mentality regarding diversity issues. It's not about blame, but knowing there are gaps to fill."

 

The Massachusetts General Hospital established a disparities committee in 2002 after the IOM issued its report documenting the disparity problem nationally. According to Betancourt, the MGH committee continues to identify and address disparity issues "wherever they may exist" at the hospital. The committee receives information from subcommittees that target "experience, education and awareness" involving racial and ethnic issues, he says.  On a regular basis, the committee's planning and findings are presented to the MGH board, executive council and other hospital leadership officials. Their reports range from non-adherence to policies, educational programs and data collection issues.

The hospital established cross-cultural training as well as interactive learning programs to allow them to "provide quality to patients of diverse cultural backgrounds," Betancourt says.

As a result, the hospital program resulted in significant awareness improvements among physicians after training 3,000 front line staff.

"If a certain group of diabetic patients are doing less well, maybe you can find some explanation, maybe it's a [literacy]  issue, maybe it's a cultural issue, and then you can target interventions to meet those patient needs," Betancourt says.

Coaching programs and patient navigators who are important tools to overcome racial and disparity issues, he says. While a doctor visit may be about 15 minutes, the coach may then spend an hour with a patient, Betancourt says.

In Chelsea, MA, two miles from Massachusetts General Hospital, hospital officials found differences in diabetes control in Latino and white populations. While 24% of the white population had diabetes, 37% of Latinos had it, he says. To improve patient conditions, a coaching program was established in which a doctor and coach worked in tandem to address the problems, Betancourt says.

 Too often, physicians don't acknowledge they need help in assessing racial or ethnic disparity issues. Some may say, "I only have 15 minutes to see a patient and 'how can I get to all these cultural issues?"

"This is really about excellence in clinical care and really [about being]  a more effective clinician," Betancourt says, referring to guidelines to help physicians and hospitals address disparity concerns. "And as much as we can get that message out, we can get greater provider buy-in."

Unfortunately, he says, some things don't change fast enough.

"We have a one-size-fits-all mentality and we leave a lot of people out of the way in which we deliver care," he says. "We need to figure out ways to improve quality, how to customize our services to meet the needs of a diverse population," he says. "It doesn't have to be minorities. It can be the elderly." For physicians and hospitals, "that's sometimes challenging and to overcome that is going to distinguish the leaders from the followers," Betancourt says.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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