End health-care disparities

When I was a medical student in San Francisco in the 1980s, I did most rotations at county and VA hospitals. Most patients were poor, and many were from racial and ethnic minority groups.

One day, two teenage Asian American boys were wheeled into the trauma emergency room, already dead. They had been slashed in the neck, victims of gang violence. These boys were not much younger than I was, and I realized all too clearly that it could have been me on that stretcher.

Most of my patients now are African Americans from Chicago's South Side.

I see patients with diabetes who have had legs amputated because their sugar, blood pressure, and cholesterol are poorly controlled. I see patients with asthma who bounce back to the emergency department because they are not using their inhalers correctly. I see patients with heart failure readmitted to the hospital because their inpatient and outpatient doctors didn't talk to one another. My reaction is not "but for the grace of God," but "Why aren't we doing better?"

Our country has been good at documenting disparities in care but poor at delivering solutions. The Affordable Care Act takes a crucial step forward by covering millions of people who would otherwise go uninsured, but access to care is not enough. Access to high-quality care is the key.

High-quality care can be nothing more complicated than giving instructions in a patient's native language or making follow-up phone calls. Technology can help make needed connections more convenient.

Health staff at the University of Pennsylvania, for example, have successfully treated African Americans with high blood pressure using an interactive computer program that shows patients the connection between controlling their high blood pressure and reducing their risk of heart disease. This effort was supplemented with a program in which patients from the same community, with well-controlled blood pressure, made monthly phone calls to peers who were having trouble with their blood pressure. They offered tips and linked them to resources in the community.

This team approach is among the many we have seen work during the last seven years in 33 disparity-reduction projects in urban and rural settings across the country.

Patients have a key role in ensuring they get high-quality care. We know that patients who speak up and actively participate in care decisions with their doctors do better than those who are passive. Yet too many African Americans and Latinos feel they are not fully at the table when decisions are made.

Since 2005, our team has reviewed hundreds of studies, funded researchers who test innovative solutions, and given technical help to groups to reduce disparities. From this, we developed a "Roadmap" that shows providers and patients how high-quality care for all patients can be achieved:

1. Show health providers their own clinical performance-breaking down the data by patient race, ethnicity, and language. Providers are motivated to address disparities when they see concrete examples in their practices. One study found that 88 percent of physicians believed that racial and ethnic disparities in diabetes care existed. Yet only 40 percent believed that such disparities existed in their own practices. Many more would discover disparities if given better information. Patients' insights can help draw attention to where the gaps lie.

2. Unite disparities reduction with quality improvement for all. Do not marginalize efforts to reduce disparities. Instead, health-care organizations should say: "Let's address all of our patients' needs."

3. Implement proven interventions. Culturally targeted care, health teams that closely monitor patients, and partnerships with families and communities are working. Successful providers use trained lay navigators to help patients move through the health system. They empower patients with interactive skills training, such as helping asthma patients practice how to use an inhaler rather than simply lecturing.

4. Create financial incentives for preventive care and attention to social determinants of health, and disincentives for costly hospitalizations and procedures. For example, Accountable Care Organizations (ACOs) are responsible for caring for a population of patients within a defined budget while meeting clinical performance standards. One of the smartest things these ACOs can do is to partner with local groups to help their patients live a healthy lifestyle. We have seen this work on the South Side of Chicago, where we link clinics with groups that provide healthy eating options for patients who live in "food deserts" without regular access to fresh produce.

Reducing racial and ethnic disparities in health care does not rely on chance or faith. Financial incentives are starting to align, but long-term solutions are local and require everyone to say that disparities in health outcomes are unacceptable. Together, we can do better.