An Organized Process Approach to Reduce
Clinical Disparities in Medicare
Lawrence Casalino MD, PhD
University of Chicago
Academy Health Annual Research Meeting, June27, 2005
Three Equations
• Quality = f(capabilities + incentives)
• Capabilities = MD capabilities +
organizational capabilities
• Effects of incentives = intended
effects + unintended effects
Two Views of Quality
• Capabilities = MD capabilities +
organizational capabilities
• Individual physician view
• Organized process view
Individual MD Effort is Not
Enough
• Focus on individual MD knowledge,
attitudes, “cultural competence” necessary
but far from sufficient
• Need organized processes in the physician
group as well
• To reduce disparities, need organized
processes directed specifically at this goal
• Organizations as well as individual MDs can
be culturally competent
Examples of Organized Processes =
“Care Management Processes = CMPs”
• identify patients who most need care
– registries
– software to stratify patients
• communicate with patients outside the
traditional office visit; support patients
in managing own illness
– telephone, e-mail, mail, Internet
– group visits
Examples of CMPs (II)
• Support MD and nurse decisionmaking
– via phone and/or biometric device
frequent contact with patients
– via reminders and “decision-support” e.g. re medication prescribing - at the
point of care
Examples of CMPs (III)
• provide feedback on performance
– to individual physicians and to physician
groups and to hospitals and health plans
– risk-adjusted for race and/or
socioeconomic status?
CMPs and Disparities
• CMPs may increase disparities if
minorities are less likely to have
access to them or less likely to
understand them
• CMPs could reduce disparities if
adapted to minority patients as
necessary
Quality Incentives Could Increase
Disparities
• Effects of incentives = intended
effects + unintended effects
Unintended Effects of Quality
Incentives? (I)
• If physicians anticipate that quality
scores will be lower for minority
patients, may avoid such patients
• If wealthier physician groups achieve
higher quality scores, they will get
richer, while the poor groups (likely to
be serving minorities) get poorer
Unintended Effects of Quality
Incentives? (II)
• Minority patients less likely to be able
to:
– access and understand public reporting of
quality measures
– act on this understanding (e.g. by
switching physicians - high quality
physicians may not be nearby)
What Might CMS Do? (I)
• Increase the capabilities of MDs and MD
groups to  quality and  disparities
– influence medical education re cultural
competence and CMPs?
– encourage development of clinical IT
capabilities?
– carefully designed rewards for quality will
encourage MD groups to invest in increasing
their capabilities
CMS and Incentives
• must be risk-adjusted and ? adjusted
for race and/or SE status, even for
process measures
• reward both absolute quality score and
percentage improvement
• ? rewards for reducing disparities