Tools for the struggle to eliminate health disparities
■ Measures of cultural competency developed by the AMA and approved by the National Quality Forum can guide key system changes.
Posted Sept. 10, 2012.
The rich historical image of America as the world’s great melting pot is a powerful and lasting one, but it is by no means a perfect metaphor for the nation. Too often, the concept of equality for all has not been borne out in reality, and even today our nation’s great diversity also contains great disparity.
The health care system is no exception. Despite the best efforts of health professionals, patient advocates and policymakers, the U.S. still struggles to eliminate pervasive health disparities, especially for racial and ethnic minorities. And physicians know better than anyone that these shortcomings can have serious consequences on patient outcomes that literally can become life-or-death matters.
Some of the entrenched barriers are hard for doctors to overcome. Tens of millions of patients in the U.S. have limited English proficiency and poor health literacy, making it difficult to ensure that they are receiving the care they need at the doctor’s office and taking the appropriate steps to stay healthy after they go home. Resources are limited throughout the system, and some practices find that despite their best intentions, they simply cannot find the investment needed to provide some patients with enhanced assistance. Other impediments are less prosaic; physicians still struggle with a level of deep-seated cultural distrust of health professionals among some minorities that persists decades after the deplorable events that prompted those suspicions.
Thankfully, there are steps that all physician practices can take to improve the situation, and organized medicine is making some important contributions. In one of the most recent big developments, the National Quality Forum endorsed a dozen new quality measures on the issues of health disparities and cultural competency. Seven of those measures approved by the Washington-based standards-setting organization came from the American Medical Association.
The official NQF seal of approval for these measures, which comes only after a rigorous review by national quality experts, opens the door for them to be used to evaluate efforts to eliminate disparities. The AMA-sponsored measures, which cover issues that include individual patient engagement, cross-cultural communication and language services, now can be used to rate hospitals and physicians, guide public data reporting, set performance-based pay and enhance other quality initiatives.
The development is historic. Never before has the quality forum adopted metrics specifically addressing disparities in care and cultural competency. But these measures are sorely needed. Despite dedicated attention to these issues, racial and ethnic minorities in the U.S. — especially blacks and Hispanics — continue to receive lower-quality care than white patients even after health conditions, coverage status and socioeconomic positions are taken into account. The entire health system needs to do a better job of communicating with all patients, treating them in a culturally sensitive way and providing access to language assistance when needed.
Not all physicians need to wait until they come into contact with a program utilizing the new NQF measures, however, before they and their patients can benefit from the expert guidance the metrics offer. The AMA-designed measures that the forum chose came from the Association’s Communication Climate Assessment Toolkit, an online resource designed to help large group practices and hospitals evaluate their own efforts to treat diverse patient populations (link).
The AMA toolkit, which has been assisting users since 2008, utilizes surveys of patients and staff to determine how well a clinic or office handles impediments to care that might be driven by patients’ language, culture, literacy, illness or fear. If patients cannot feel comfortable talking to a receptionist, filling out a medical form or understanding a nurse’s instructions, they cannot achieve the connection with their physicians that surely will be needed to give them the best care possible. By following the AMA’s recommendation to hire a licensed, expert consultant to help interpret the in-depth assessments offered by the free surveys, a practice will be able to identify and implement the significant organizational changes that might be needed to implement the best possible cultural competency plan.
The disparity and cultural competency issues are prime examples of how physicians have responsibilities to patients that are not just clinical but also ethical. The AMA recognizes this, and that’s why the toolkit came out of an Association initiative known as the Ethical Force Program, an effort that is steeped in the knowledge that the provision of health care is, at its very heart, a moral enterprise.
The health system cannot give up on the promise of giving all patients — no matter where they were born, what language they speak or what skin color they have — the care that they need and deserve. With the latest boosts from organized medicine and the quality improvement community, those who are in the best positions to help achieve that promise have some added strength and guidance to finish the job.