ON THE HORIZON
All differences in such conditions as cancer, diabetes and infant mortality will not be eliminated before the Healthy People 2010 deadline for zero disparities. Nonetheless, new insights are leading to new approaches. In the future, expect more nuanced understanding of groups, more focus on providers' roles in disparate access, attention to program design, and a view of disparity as a sign of poor quality.
Past studies of disparity focused on shortfalls in access and outcomes for African Americans and Hispanics. Census codes lump professionals with advanced degrees with non-literate refugees. Today, newcomers from all corners of the globe confront a range of medical problems and linguistic and cultural barriers to care. Recent research has highlighted important differences within census categories-such as "Hispanic" and "Asian"-while market research has produced tools for pinpointing messages. Even with detail about subgroups, states have difficulty using national data to understand challenges to access that face specific groups, such as tribal entities and refugee communities. In the future, expect more carefully targeted programs that take into account health, linguistic and cultural needs of affected groups, including medical translation and innovative culturally congruent outreach-promatora programs, for example.
The IOM report, Unequal Treatment, and recent studies from Kaiser and Commonwealth highlight the critical importance of patient-physician interactions in disparities (see "In the Abstract"). Patients' and providers' expectations, uncertainty and failure to communicate hurt the quality of care; stereotyping and bias lead to poorer outcomes. As the health care community absorbs the lessons and recommendations of these studies, look for a renewed emphasis on recruiting and training minority providers and more training for all practitioners on cultural competence, bias and the need to communicate effectively across racial, ethnic and other group membership.
The studies point out that health care disparities are part of a broader societal context of discrimination and persistent inequality that drive a cycle of poverty, low expectations and poor health. A health system that makes poorer patients deal with a fragmented system and episodic care undercuts efforts by individual providers to build rapport with their patients. Reducing disparities requires strategies that compensate for-or at least do not worsen-the effects of poverty, poor education and diminished access. One recommendation: changes in reimbursement and provider incentives should not fall the hardest on the poorest groups. This will be a challenge to states that are struggling with budget and Medicaid shortfalls.
Expect more accountability at every level for differences in care. Health plans can combat disparities if they have incentives and information; quality activities and problem solving can find and address differences in the rates at which various groups receive appropriate care. The Agency for Healthcare Research and Quality (AHRQ) is measuring racial disparity as part of a national health care quality report. More Medicaid and Medicare plans may accept the invitation to benchmark progress in eliminating disparities as part of their quality assurance activity as data become available from state agencies and civil rights liability concerns are addressed.
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