It's been nine years since the Institute of Medicine released its landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, and while some progress has been made, health disparities continue to be a vexing problem. Joseph Betancourt, M.D., director of the Disparities Solutions Center at Massachusetts General Hospital, says collecting racial, ethnic and cultural data on patients remains one of the biggest challenges. For the past few years, Massachusetts General not only has been collecting the data, but also turning it into actionable information. The hospital launched a program to address quality and equity among diabetes patients in Boston's Chelsea neighborhood. Betancourt will lead a session about health disparities at the Health Forum and the American Hospital Association Leadership Summit July 17-19 in San Diego. He spoke with H&HN Senior Editor Matthew Weinstock.
The IOM identified equity of care as one of its six pillars several years ago, but it still seems to be a major challenge for providers. Why?
I think equity has been slow to move for some obvious reasons that we are comfortable discussing and some that we are less comfortable discussing. Among the obvious ones, I would say there is still a need and desire in the field for concrete solutions to better identify and address disparities. If you compare this with patient safety, very quickly after To Error is Human, you had systems being set up to monitor medical errors. There hasn't been as much expediency in setting up the systems to collect race and ethnicity data, which is sine qua non for this work. Absent that, everything kind of stalls.
Unlike safety, where reimbursement and accreditation have driven that field, we haven't had the same set of pressures on the disparities side, although that is coming. I think it is positive that the Joint Commission has come to the fore; the National Quality Forum is setting measures.
When it comes to discussion around race, ethnicity and disparities, those are more heavily charged. People can get defensive, or concerned about what's being said. There's a passive resistance and some of it is discomfort with the conversation. I think that has limited leadership support and buy-in. People are concerned about what they'll see. So what you get instead is a larger debate—"Well, what's our return on investment? Why should we collect it?"—that we don't necessarily get around some of the other IOM pillars. With safety, the things that moved that field were accreditation and issues around reimbursement. As we see similar moves in this area, we'll be forced to overcome these challenges.
How do you turn data into actionable information?
You need to ensure you are collecting information that is usable. For us, we've been able to look at measures that were off the shelf. We began with the very basic. We had the core measures, we had HEDIS outpatient measures and we had patient satisfaction measures. We started to connect all of those to our race and ethnicity data. That's not always as easy as just connecting the wires. These IT systems don't always speak to each other; you need to do a lot in terms of building patches to make them connect.
If I were to encourage any hospital to do anything, it would be to begin incrementally. Begin to connect the data to measures that they already have to report, and spend the time connecting those wires.
We decided that we wanted to build an annual report that looks at how we performed in all populations. Our disparities dashboard literally gives us data on all patients stratified by race and ethnicity with congestive heart failure, acute myocardial infarction, community-acquired pneumonia and surgical infection prevention. That allows us to identify any particular difference in care patients are receiving or any disparities.
Can you talk about the example of diabetes and Latinos in Chelsea?
We were monitoring our diabetes care, particularly because of a pay-for-performance contract. We developed diabetes registries and intersected those with race and ethnicity data. We saw that our Latino patients not only had higher hemoglobin A1c, which is an indication of poor diabetes control, but they also get tested less frequently.
The beauty is we can get down to the patient level by stratifying these registries. We thought it would be important to reach out to those patients and help them better manage their diabetes and sort out what was impeding them.
We created a health coach program and hired an individual who was not a health care professional, but someone trained in motivational interviewing. We trained him in cross-cultural care and on the basics of diabetes.
That individual has a registry of patients and is able to identify those whose diabetes is in poor control. When they come to see their doctor at the health center, he will set up an appointment with them and spend an hour going over soup-to-nuts what the challenges might be in managing their diabetes. He'll help them address those challenges. I should say, he saw all patients, not just Latinos. He was able to improve outcomes for all patients. So he improved quality and reduced the gap between them.
Tell me about the center's disparities Leadership Program
It was created four years ago. We wanted to provide guidance, technical assistance and customized solutions to health care organizations around the country. It is a one-year executive education program for leaders from hospitals, health plans and health centers. They apply and get CEO sign-off and commit to doing something as simple as developing a strategic plan, but also to doing more advanced work like learning how to create disparities data and a disparities dashboard, and how to develop and evaluate interventions. They get two days of intense training at Mass General on quality, safety and disparities—all of the things that give you the foundation.