Fighting Unequal Treatment
The Robert Wood Johnson Foundation and a Quality-Improvement Approach to Disparities
Ensuring that all Americans have access to quality health care is one of the major goals of The Robert Wood Johnson Foundation (RWJF), as is improving the quality of health care for people with chronic conditions. Working toward this goal means that we must eliminate the embarrassing and unacceptable gaps in health care experienced by racial and ethnic minorities. Research indicates that Americans do not receive half of the care that experts recommend,1 but the evidence also indicates that these quality gaps are even worse for racial and ethnic minorities.2
Disparities in treatment exist across a wide range of chronic conditions, and the evidence of differential treatment is particularly strong with regard to treatment for cardiovascular conditions such as myocardial infarction and congestive heart failure.3 Even though disparities in care have not been conclusively linked to disparities in health outcomes, many experts believe that persistent patterns of lower-quality care for minority Americans do contribute to worse health outcomes, which could explain in part the disproportionate impact of heart disease on minority Americans. Mortality rates from cardiovascular disease are higher among blacks than whites,4 and one study found that heart disease accounted for nearly one third of the overall mortality difference between black and white patients.5 For all of these reasons, efforts to reduce disparities in cardiovascular care are likely to be particularly important in closing gaps in care and will be a high priority for RWJF in the next half decade. This editorial describes the foundation’s approach to reducing racial and ethnic disparities in health care and the underlying rationale for the strategy.
For RWJF, developing a new targeted strategy for funding work to reduce racial and ethnic disparities in care required an immediate emphasis on discovering or helping to develop replicable solutions. We believe in supporting projects that have measurable impact on Americans’ health and health care. Many worthy projects or initiatives have either appeared on the scene or picked up momentum since the Institute of Medicine published Unequal Treatment in 2002, its landmark report reviewing the extensive evidence on racial and ethnic disparities in health care. Many of these efforts are, by necessity, focused on long-term goals (such as the diversification of the healthcare professions) or hard-to-measure goals (such as training providers to be more culturally competent) that may take years to bear fruit by way of concrete, measurable improvements in the quality of health care.
These approaches are important and necessary; however, RWJF chose to take a complementary path with shorter-term goals. Although we had supported many projects aimed at improving the health and health care of racially and ethnically diverse populations, our disparities strategy was going to be different: a tightly targeted effort to help healthcare systems focus on healthcare disparities experienced by racial and ethnic populations as a quality-of-care problem, with quality-improvement methodologies as the starting point for solutions.
Therefore, the Foundation’s approach to disparities builds as much on our work in quality improvement as it does on our programs such as Hablamos Juntos (“We Speak Together”), which supports demonstration projects to improve communication between providers and patients who have limited English-speaking skills. We will help healthcare systems (more specifically, health plans, providers, purchasers, and consumers) ensure that addressing racial and ethnic disparities in treatment is a high priority in their ongoing efforts to improve the quality of care for patients. In fact, we believe that healthcare systems cannot effectively move their quality-improvement goals forward without specifically taking on the embedded problem of racial and ethnic disparities in treatment.
For the next 5 years, the Foundation is committed to a series of targeted investments to different entities that play major roles in America’s healthcare system. In addition, we are supporting research to improve understanding of the contributing factors behind disparities between white and nonwhite patients and to use this knowledge to help health plans and providers identify disparities in care where they occur and design interventions to address them. We will focus on particular conditions, such as diabetes and cardiac disease, which have a particularly large impact on minority populations and for which there is a strong evidence base for a recommended standard of care for all patients.6 Although we are aware that factors beyond the influence of the healthcare system obviously contribute to gaps in treatment (such as health insurance coverage, the quality of one’s provider in a particular geographic area, and personal health behaviors), our efforts will stimulate healthcare systems to develop interventions that ensure minority patients are receiving high-quality care even within the constraints of today’s healthcare system and the ongoing struggle our society has with issues of equity and race.
The Foundation’s approach to disparities is unfolding along several tracks. First, we concentrated on launching a research agenda that would answer pressing questions for the field and our strategy development. In particular, our portfolio of research projects seeks to build a broader knowledge base about factors that contribute to racial and ethnic disparities in treatment in ways that would illuminate potential interventions that healthcare systems could undertake. We are supporting research that continues to make the case to healthcare professionals and policy makers that disparities in care persist across multiple treatment areas and should be addressed. Our research plans include tracking trends in disparities over time, understanding better how the local quality of one’s healthcare system affect differences in care, and evaluating demonstration projects launched by RWJF and others that are specifically designed to reduce disparities.
Our research agenda also encompassed a series of projects to help our grantees and others work on the problem of racial and ethnic disparities with greater dispatch and with increased knowledge at their disposal. For example, we recognized that health plans and providers might be reluctant to measure racial and ethnic differences in treatment for a multitude of reasons, some of which are impeding efforts under way in the quality-improvement arena to move toward greater transparency in the healthcare system. Because the ability to measure both problem and progress is a central tenet of the drive toward improving the quality of health care, the race/ethnicity data question was, in fact, a threshold question to which the Foundation sought answers from the beginning of this initiative.
Second, we are now in the phase of launching demonstration projects that help health plans and providers implement targeted efforts to reduce gaps in care between whites and nonwhites. Health plans are well positioned to take on racial and ethnic disparities because of the capacity to analyze differences in care across large patient populations and their experience with quality-improvement activities. However, we do not think demonstrations with health plans alone can succeed in producing replicable solutions unless we also help providers change the ways in which they deliver health care to patients, particularly minority patients, who may often live in areas where healthcare systems are the most lacking in resources.
Third, we are committed to raising awareness about the existence and causes of racial and ethnic disparities. Along with The Henry J. Kaiser Family Foundation and other organizations representing physician, public health, and business groups, RWJF took an initial step to raise awareness among physicians about racial and ethnic disparities in care with an initial focus on cardiac care. Although the organizations involved with this initiative, called “Why the Difference,” were engaged by the topic (N. Lurie et al, unpublished data, 2002), most of them also demonstrated a need for concrete steps that providers could take to raise the quality of health care for minority Americans.
Because of these insights about the need for concrete solutions gleaned from the “Why the Difference” initiative, RWJF will launch a new hospitals disparities initiative, focused solely on improving cardiac care for patients of color, called “Expecting Success: Excellence in Cardiac Care.” The program, which is currently in the midst of its application and selection process, will announce its grantees in September 2005. The hospital grantees will be asked to engage in a collaborative process involving technical assistance and information sharing, with the ultimate goal of improving cardiac care for black and Latino patients with myocardial infarction or congestive heart failure.
RWJF chose this initial focus on heart disease for several reasons. First, the evidence for what constitutes recommended care in these areas is clear. Second, the evidence of racial and ethnic disparities in cardiac care is also clear. Third, as mentioned previously, the impact of heart disease on blacks and Hispanics is high. Furthermore, the metrics for quality cardiac care already exist and are being disseminated widely by the Centers for Medicaid and Medicare Services as part of its National Voluntary Hospital Reporting Initiative.7
Once we know more about solutions to reduce inequities in our healthcare system, our work will not end. Critical to each component of RWJF’s disparities strategy is sharing results with others in the field. All of the learning from RWJF-funded projects—efforts that are sometimes purely research, sometimes demonstration, and sometimes hybrids of both—will be shared widely with interested stakeholders in the field.
In this era of modern health care, gaps in the quality of care are unacceptable, particularly when these gaps are worse for patients from particular racial and ethnic backgrounds. A quality-improvement approach to racial and ethnic disparities holds considerable promise because of its potential to bypass or make less confounding some of the issues that people believe are insolvable within the context of the healthcare system—issues such as bias, prejudice, and unequal patterns of access to the healthcare system that have existed for decades. Although we care deeply about these issues and do not shrink from taking on difficult questions, the healthcare system needs answers to address inequities in care, not further controversy. By emphasizing quality as an achievable goal at the microsystem level (by spurring improvement within individual health plans and hospitals that can be held up and ultimately spread as lessons for the entire system), we believe that health care can be improved for all Americans in our lifetime.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
The Robert Wood Johnson Foundation, based in Princeton, NJ, is the nation’s largest philanthropy devoted exclusively to health and health care. It concentrates its grant making in 4 goal areas: To assure that all Americans have access to quality health care at reasonable cost; to improve the quality of care and support for people with chronic conditions; to promote healthy communities and lifestyles; and to reduce the personal, social, and economic harm caused by substance abuse—tobacco, alcohol, and illicit drugs.
Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2002.
Kaiser Family Foundation/American College of Cardiology Foundation. Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2002.
American Heart Association. Heart Disease and Stroke Statistics—2004 Update. Dallas, Tex: American Heart Association; 2003.
Wennberg J, Fisher E, Skinner J. Geography and the debate over Medicare reform. Health Aff (Millwood). 2002; Suppl Web Exclusives: W96–W114.
Centers for Medicare and Medicaid Services, National Voluntary Hospitals Reporting Initiative [now known as the Hospital Quality Alliance]. Improving Care Through Information. Available at: http://www.cms.hhs.gov/quality/hospital/Listof10Measures.pdf. Accessed November 17, 2004.