n Pursuit of High-Value Healthcare: The Case for Improving Quality and Achieving Equity in a Time of Healthcare Transformation JOSEPH R . BETANCOURT S U M M A R Y • The passage of the Patient Protection and Affordable Care Act and current efforts in payment reform signal the beginning of a significant transformation for the US healthcare system. As we embark on this transfor- mation, disparities have emerged as the hallmark of low-value healthcare—care that does not meet quality standards, is inefficient, and is usually of high cost. A new set of structures is being developed to facilitate increased access to care that is cost-effective and high in quality—otherwise known as high-value health- care. Addressing disparities and achieving equity are the perfect target areas for recouping value, and doing so will pave the way for high-value healthcare. As healthcare leaders make difficult choices, they should consider the realities of healthcare equity. Eirst, racial and ethnic disparities in healthcare persist and are a clear sign of poor-quality, low-value healthcare. Second, the root causes of these disparities are complex, but a well-developed set of evi- dence-based approaches is available to help leaders address healthcare ineq- uity. Third, evidence suggests that being inattentive to the root causes of dis- parities adversely affects efficiency and an organization's bottom line. Einally, if healthcare organizations are progressive, thoughtful, and prepared for success in such an environment, a new healthcare system that offers accessible, high- value, equitable, culturally competent, and high-quality care to all is well within reach. Joseph R. Betancourt, MD, is director of the Disparities Solution s Center and of Mul- ticultural Education for Massachusetts General Hospital, both in Boston. He also is a cofounder of Quality Interactions Inc., located in Cambridge, Massachusetts. i 6 • F R O N T I E R S O F H E A L T H S E R V I C E S M A N A G E M E N T 3 0 : 3 INTRODUCTION The passage of the Patient Protection and Affordable Care Act (ACA) and current efforts in payment reform signal the beginning of a significant transformation for the US healthcare system. A new set of structures is being developed to facili- tate increased access to care that is cost- effective and high in quality—otherwise known as high-value healthcare. Pursuing high-value healthcare is the ultimate goal, and healthcare leaders across the country are faced with the daunting challenge of succeeding—perhaps just surviving—in this brave new world (Böhmer 2011). In the area of quality, we are not with- out a basic blueprint, however. Cuided by the Institute of Medicine (IOM) report Crossing the Quality Chasm (Corrigan, Donaldson, and Kohn 2001), we have charted a path to deliver care that is safe, efficient, effective, timely, patient centered, and equitable. Significant gains have been made in this effort, particularly in the area of patient safety (Hosford 200.

1. n Pursuit of High-Value Healthcare:
The Case for Improving Quality and
Achieving Equity in a Time of Healthcare
Transformation
JOSEPH R . BETANCOURT
S U M M A R Y • The passage of the Patient Protection and
Affordable Care Act
and current efforts in payment reform signal the beginning of a
significant
transformation for the US healthcare system. As we embark on
this transfor-
mation, disparities have emerged as the hallmark of low-value
healthcare—care
that does not meet quality standards, is inefficient, and is
usually of high cost.
A new set of structures is being developed to facilitate
increased access to care
that is cost-effective and high in quality—otherwise known as
high-value health-
care. Addressing disparities and achieving equity are the perfect
target areas for
recouping value, and doing so will pave the way for high-value
healthcare.
As healthcare leaders make difficult choices, they should
consider the
realities of healthcare equity. Eirst, racial and ethnic disparities
in healthcare
persist and are a clear sign of poor-quality, low-value
healthcare. Second, the

2. root causes of these disparities are complex, but a well-
developed set of evi-
dence-based approaches is available to help leaders address
healthcare ineq-
uity. Third, evidence suggests that being inattentive to the root
causes of dis-
parities adversely affects efficiency and an organization's
bottom line. Einally, if
healthcare organizations are progressive, thoughtful, and
prepared for success
in such an environment, a new healthcare system that offers
accessible, high-
value, equitable, culturally competent, and high-quality care to
all is well within
reach.
Joseph R. Betancourt, MD, is director of the Disparities
Solution
s Center and of Mul-
ticultural Education for Massachusetts General Hospital, both in
Boston. He also is
a cofounder of Quality Interactions Inc., located in Cambridge,
Massachusetts.
i 6 • F R O N T I E R S O F H E A L T H S E R V I C E S M A
N A G E M E N T 3 0 : 3

3. INTRODUCTION
The passage of the Patient Protection and
Affordable Care Act (ACA) and current
efforts in payment reform signal the
beginning of a significant transformation
for the US healthcare system. A new set
of structures is being developed to facili-
tate increased access to care that is cost-
effective and high in quality—otherwise
known as high-value healthcare. Pursuing
high-value healthcare is the ultimate goal,
and healthcare leaders across the country
are faced with the daunting challenge of
succeeding—perhaps just surviving—in
this brave new world (Böhmer 2011).
In the area of quality, we are not with-
out a basic blueprint, however. Cuided
by the Institute of Medicine (IOM) report
Crossing the Quality Chasm (Corrigan,
Donaldson, and Kohn 2001), we have
charted a path to deliver care that is safe,
efficient, effective, timely, patient centered,
and equitable. Significant gains have been

4. made in this effort, particularly in the area
of patient safety (Hosford 2008; Romano
et al. 2003). However, one key pillar of
quality—achieving equity—has remained
elusive and has garnered significantly
less attention than have the other quality
mandates.
Equity in healthcare is the principle that
quality of care should not vary on the basis
of patient characteristics, such as race or
ethnicity. This aim emerged from the find-
ings of another IOM report, titled Unequal
Treatment: Confronting Racial and Ethnic
Disparities in Health Care (Smedley, Stith,
and Nelson 2003). The report found that
even with the same insurance and socio-
economic status and when comorbidities,
stage of presentation, and other confound-
ing factors are controlled for, racial or eth-
nic minorities often receive a lower quality
of healthcare than do their white counter-
parts (see Exhibit i). The latest National
Healthcare Disparities Report, released in

5. 2012, confirms this problem persists today
(AHRQ 2012).
As we embark on this healthcare
transformation, disparities have emerged
as the hallmark of low-value healthcare—
care that does not meet quality standards,
is inefficient, and is usually of high cost.
Between 2003 and 2006, the combined
direct and indirect cost of health dispari-
ties was $1.24 trillion (LaVeist, Caskin,
and Richard 2009). Addressing disparities
and achieving equity are the perfect target
areas to recoup value, and doing so will
pave the way for high-value healthcare. In
the end, if we are to be successful in our
pursuit of value, we must be prepared to
deliver high-quality care to an increasingly
diverse population—especially given that
racial or ethnic minorities will comprise
48 percent of the 32 million individu-
als who will be newly insured under the
ACA (RWJF 2013)—and other vulnerable
patients across all backgrounds.

6. For example, regarding ethnic minori-
ties, research demonstrates that compared
to whites, minorities
• tend to suffer more medical errors with
greater clinical consequences (Divi et
al. 2007; Flores and Ngui 2006; Schyve
2007),
• experience longer lengths of hospital
stay for the same clinical conditions
(Ash and Brandt 2006),
• experience higher rates of avoidable
hospitalizations and higher 30-day
readmission rates for congestive heart
failure (Alexander et al. 1999; Jiang et
al. 2005; MedPAC 2008; Rathore et al.
2003),
m
losEPH R. B E T A N C O U R T • 17

7. E X H I B I T 1 where Disparities Are Found
Areas of Disparity Examples from Literature
Utilization of cardiac diagnostic and
therapeutic procedures in the emergency
department
African Americans are referred less often than
are whites for cardiac catheterization
(Schulman et al. 1999) and bypass grafting
(Kressin and Petersen 2001; Petersen et al.
2002)
Administration of analgesia for pain control African Americans
and Latinos receive less
pain medication in the emergency department
than do whites for long bone fractures
(Pletcher et al. 2008) and for cancer pain once
admitted (Bernabei et al. 1998; Green et al.
2006)
Surgical treatment of lung cancer African Americans receive
curative surgery less

8. often than do whites for non-small cell lung
cancer (Bach et al. 1999)
Referral to renal transplantation African Americans with end-
stage renal disease
are referred less often to the transplant list
than are whites (Ayanian et al. 1999a)
Treatment of patients hospitalized with
pneumonia and congestive heart failure
African Americans receive less optimal care
than do whites when hospitalized for these
conditions (Ayanian et al. 1999b)
Outcomes of myocardial infarction Elderly African American
women have the
highest adjusted in-hospital mortality rate
(Vaccarinoetal. 2005)
• experience more test ordering
(particularly when a language barrier
exists) for similar conditions, and
• are subject to underutilization in areas

9. that provide clinical benefits according
to evidence-based guidelines, such as in
management of cardiovascular disease
and cancer (Jha et al. 2007, 2008; Sack
2008).
In the near future, many instruments
will be used to drive value in healthcare,
such as accountable care organizations
(ACOs) and patient-centered medical
homes (PCMHs). Financial disincentives
for hospital readmissions and medical
errors, payment on the basis of patient
experience, rules for public reporting, a
focus on care transitions, and calls for
population and chronic disease manage-
ment are just a few avenues along which
quality of care will become the central
theme of healthcare redesign.
Furthermore, as community benefit
and not-for-profit status take on greater
importance for hospitals across the coun-
try gearing up to comply with the ACA, ad-

10. dressing racial and ethnic disparities can
represent a valuable portfolio of work that
will document healthcare organizations'
adherence to new regulations (Massachu-
setts General Hospital 2006; Day 2006).
18 F R O N T I E R S O F H E A L T H S E R V I C E S M A N
A G E M E N T 3 0 : 3
In short, improving quality, addressing
disparities, and achieving equity are no
longer just the right things to do— t̂ hey
also are the smart things to do, given the
new set of financial structures developed
to drive quality and value.
WHAT ARE THE ROOT CAUSES OF
DISPARITIES?
There is little doubt that certain social de-
terminants—low education levels, low so-
cioeconomic status, inadequate and unsafe
housing, racism, and living in proximity
to environmental hazards, for example—

11. disproportionately affect minority popula-
tions and contribute to their poor health
outcomes (Andrulis 1998; Antonovsky
1968; Elores et al. 2002; Hinkle et al.
1968; Pincus and Callahan 1995; Pincus
et al. 1998; Williams 1990). Similarly, lack
of access to care—a particular problem for
minority populations—takes a significant
toll, as uninsured individuals are less likely
than those with health insurance to have
a regular source of care, are more likely to
delay seeking care (Giacovelli et al. 2008;
Stevens, Seid, and Halfon 2006), and are
less likely to receive needed care (Har-
graves 2002). Lack of access ultimately
results in avoidable hospitalizations,
inappropriate utilization of the emergency
department, and adverse health outcomes
for minorities in the United States (Byrd
1990; Williams et al. 1997).
Unequal Treatment argues that racial
and ethnic disparities in care quality con-
tribute to disparities in health outcomes.
The root causes of such disparities are

12. complex; Unequal Treatment groups them
according to the following factors (Smed-
ley, Stith, and Nelson 2003):
• Health system factors: the complexity
of the healthcare system, the difficulty
minority patients may encounter
navigating it, and the lack of interpreter
services to assist patients who have
limited English proficiency
• Provider factors: providers' stereotyping
of patients, the impact of race and
ethnicity on clinical decision making,
and clinical uncertainty due to poor
communication
• Patient factors: patient mistrust,
refusal of services, poor adherence to
treatment, and delays in seeking care
Health System Factors: Challenges in
Navigating the Healthcare System
Several seminal reports demonstrate that

13. multiple barriers prevent immigrants,
patients with limited English proficiency
or low health literacy, and minorities from
receiving timely, effective care, leading to
disparities. Eor instance, patients may not
be familiar with the use of primary care
services, relying instead on urgent care or
emergency services (Collins et al. 2002).
They may not understand how to prepare
for a procedure, access specialty care,
or follow up on an abnormal test result
(Scheppers et al. 2006).
Provider Factors: Barriers to
Communication and Rapport
Several studies show that providers commu-
nicate less effectively with minority patients
and those with language barriers and are
less likely to build trusting relationships
with minority patients than with white pa-
tients (e.g., Gordon et al. 2006). For exam-
ple, a national survey found that Hispanics
were twice as likely as whites to report one
or more communication problems, such as
not understanding their doctor, feeling their

14. doctor did not listen to them, or being afiaid
to ask questions; a third of Hispanics and
a quarter of African Americans and Asian
Americans have experienced these commu-
nication problems (Collins et al. 2002).
-i
C
73
m
JOSEPH R. B ET A NCOUR T • 19
w h e n providers do not understand
patients' unique perspectives and values,
poor communication can lead to patients'
dissatisfaction and distrust (e.g., Schenker
et al. 2008); cause patients to misunder-
stand their illness and treatment plan (Bet-
ancourt. Carrillo, and Green 1999); lead

15. to clinical uncertainty and misdiagnosis;
and engender overreliance on objective
testing, such as CT (computed tomogra-
phy) scans in the emergency department
(e.g., Smedley, Stith, and Nelson 2003).
Patient Factors: Mistrust and Lack of
Fol low-Up
Whether a patient accepts and follows
through with a provider's recommenda-
tions depends on the balance of several
key factors, including level of mistrust
and cultural beliefs. For example, a survey
by the Kaiser Family Foundation (1999)
found that 65 percent of African Ameri-
cans and 58 percent of Hispanics, com-
pared to 22 percent of whites, were afraid
of being treated unfairly on the basis of
their race and ethnicity when accessing
healthcare services. This lack of trust
can result in inconsistent care delivery
or "doctor shopping," self-medication,
and increased demand for referrals and
diagnostic tests by patients (Safran et al.
1998). In addition, minority patients who

16. have low general and health literacy are
significantly limited in efforts to share in
the decision making about and engage in
their own care— t̂ wo major areas that are
receiving great attention as part of quality
improvement.
A BLUEPRINT FOR IMPROVING
QUALITY AND ACHIEVING EQUITY
Just as Crossing the Quality Chasm (Corri-
gan, Donaldson, and Kohn 2001) serves as
a blueprint for action related to improving
healthcare quality. Unequal Treatment
provides a road map for ensuring health-
care equity by offering a set of recommen-
dations for addressing and eliminating
disparities on the basis of race and ethnic-
ity. Interestingly, several of these recom-
mendations can be readily integrated into
the quality improvement efforts being de-
signed and implemented today. Moreover,
they are synergistic with efforts to improve
data collection, measurement, quality, and
outcomes. Smedley, Stith, and Nelson

17. (2003) recommend the following steps:
1. All healthcare organizations should
collect the race, ethnicity, language
preference, and socioeconomic status
of all patients to whom they provide
care.
2. Demographic data should be
linked to quality data, and quality
data should be stratified by these
demographics to routinely monitor
performance and identify disparities
inquality of care.
3. Once disparities are identified,
quality improvement tactics should
be deployed to address and eliminate
those disparities. Healthcare
organizations may do so by ensuring
the broad implementation of
evidence-based guidelines and the
use of multidisciplinary teams and
community outreach.

18. 4. To support this work, all healthcare
professionals should be trained in
(a) the root causes of disparities,
(b) the impact of patient race and
ethnicity on clinical decision making,
and (c) cultural competence—or
cross-cultural communication—so
that they can communicate with and
provide high-quality care to diverse
populations.
2 0 • F R O N T I E R S O F H E A L T H S E R V I C E S M A
N A G E M E N T 3 0 : 3
5. Efforts to diversify the healthcare
workforce should be seen as essential.
6. Dedicated interpreter services
should be made available to patients
with limited English proficiency to
improve diagnostic and therapeutic
outcomes and to minimize medical
errors and risks.

19. 7. Patients should be empowered
and activated as pariners in their
own care and should be assisted in
navigating complex clinical situations
so that they can avoid inappropriate
utilization of services or lack of
follow-up.
8. Healthcare providers should be
educated in the areas of health
• disparities, cultural competence, and
the influence of race and ethnicity on
clinical decision making.
The Disparities Leadership Program
Some progress has been made in execut-
ing these recommendations, but we have a
long way to go in reaching equity. A practi-
cal litmus test of this progress has been my
experience with the Disparities Leadership
Program (DLP). The DLP is a year-long
executive education program designed and
offered by the Disparities