Qualitative Analysis

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 Solutions 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.

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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 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 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.

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),

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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 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 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- 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).

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In short, improving quality, addressing disparities, and achieving equity are no longer just the right things to do— t̂hey 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— 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 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 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 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).

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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 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 have low general and health literacy are significantly limited in efforts to share in the decision making about and engage in their own care— t̂wo 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 (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.

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.

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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.

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 Solutions Center at Massachusetts General Hospital, which I direct. The DLP—the only program of its kind in the United States—combines face- to-face education with distance learning to equip healthcare leaders with (i) in-depth knowledge of the field of disparities, includ- ing root causes and up-to-date research; (2) cutting-edge quality improvement tactics for identifying and addressing disparities; and (3) leadership skills to implement these tactics and help transform their organi- zations in this time of rapid healthcare system change. (See the sidebar for more information about the DLP.)

Several key lessons have emerged from my work in the DLP that can provide guid- ance for healthcare leaders interested in improving quality and achieving equity. Each lesson is discussed in the sections that follow.

Secure Leadership and Staff Buy-In If the healthcare leaders of an organization are either unaware of racial and ethnic disparities in healthcare or unconcerned about addressing them, efforts to achieve equity will see limited success. The key to launching any successful effort is to ensure that leaders understand the link be- tween disparities and cost, quality, safety, risk management, and value. As long as efforts to improve access to care for all are seen as a "special project," they will be marginalized, unsuccessful, and not in- stitutionalized in general quality improve- ment systems and initiatives. Securing leadership buy-in at all levels—including the board, the C-suite, senior leaders, op- erational managers, and frontline staff— is the first and most critical part of the process. It is from this buy-in that culture, systems, and resources flow. (Guides are readily available to help organizations in this process; see Betancourt et al. [2008].)

Develop a Strategic Plan Once leadership buy-in is secured, a detailed strategic plan that includes goals, objectives, assigned responsible parties, and a timeline needs to be put in place. As with other efforts, this plan ensures a steady march toward success and prevents the "sizzle and fizzle" phenomenon often seen with initiatives.

Organizations can begin developing their strategic plan for ensuring equal ac- cess by creating a multidisciplinary dispar- ities committee that represents staff from

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ABOUT THE DISPARITIES LEADERSHIP PROGRAM This year-long executive education program targets leaders of hospitals, health plans, and community health centers and helps them develop a strategic plan or advance a project to eliminate racial and ethnic disparities in healthcare within their organization.

Since 2007, the DLP has trained seven program classes, which included 211 participants from 98 organizations (21 health plans, 47 hospitals, 20 community health organizations, 7 professional organizations, a hospital trade organization, a federal agency, and a local government agency) representing 29 US states, Puerto Rico, and Switzerland. DLP organizations serve as dissemination and translation sites for a variety of disparities interventions. Recently, the program underwent an extensive evaluation by an external party and was found to be highly successful.

To date, organizations that have participated in the DLP have tended to be early adopters of efForts to address disparities and have progressive leaders who see the importance of this work. That said, the overwhelming majority of organizations that have participated in the DLP are in the early stages of development and maturity in their efforts to draft strategic plans; fortify their efforts to collect race and ethnicity data; and create performance measurement tools, such as a disparities dashboard, equity reports, or targeted disease registries. A select few have begun to experiment with interventions, some focused on disease management (e.g., diabetes, congestive heart failure, infant mortality), others focused on patient safety, and a handful focused on preventing avoidable hospitalizations or readmissions. (Visit viww.mghdisparitiessolutions.org.)

quality, operations, patient registration, member services, social services, human resources, and nursing as well as physi- cian leaders firom several clinical services. This committee is responsible for assess- ing steps being taken currently in the area of disparities (such as whether patient race or ethnicity and primary language data are collected) and crafiing the initial strategic plan. (The National Public Health and Hospital Institute [2008] öfters resources to assist with this process.)

Collect Data The ability of healthcare organizations to identify and address racial and ethnic disparities hinges on the efficiency of their patient race/ethnicity information collec- tion process. Collecting racial, ethnic, and language information can be modeled on proven processes, eliminating the need to "reinvent the wheel" for this most critical function—the foundation of all dispari- ties- and equity-related work. Guidance is available on how to set up an effective process, including which race and ethnic- ity categories should be used, as well as the importance of collecting information about socioeconomic status (via educa- tional level), racial/ethnic subgroup (such as "Puerto Rican" within the Hispanic/ Latino group), and primary language.

For example, the Health Research and Educational Trust (Hasnain-Wynia et al. 2007) and the Disparities Solutions Center (2006a, 2006b) öfter guidance on opera- tionalizing these processes, including what to ask patients (key categories), when to ask it (during registration), how to ask it (with an appropriate preamble to ensure patients understand why their information is being collected), how to train staff to ask it (reg- istrar training), how to make sure staftare asking it correctly (quality assurance), and

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what additional technical and other sup- poris are necessary (e.g., technical specifica- tions, poster campaign for patients).

Make the Data Useful Collecting race, ethnicity, and language data is not enough to address disparities. Once these data are collected, healthcare organizations must develop routine moni- toring and measurement tools to analyze and review performance and identify dis- parities in quality. Some healthcare organi- zations have developed disparities dash- boards and equity reports, which enable them to routinely monitor variations in hospital core measures (acute myocardial infarction, community-acquired pneumo- nia, surgical-infection prophylaxis, conges- tive heart failure). Healthcare Effective- ness Data and Information Set measures (e.g., diabetes management; completion of preventive tests, such as mammograms and colon cancer screening), and even new measures with clear financial relevance (e.g., congestive heart failure readmission rates, avoidable hospitalizations, patient experience).

Some key areas have received less attention but should be monitored and stratified—such as safety events by race, ethnicity, and language—so they can be documented and assessed for root causes and improvements. A few organizations have developed disease registries stratified by race, ethnicity, and language spoken to identify quality improvement interven- tions to meet the cultural or linguistic needs of patients who are not at their target measures for diabetes. By develop- ing routine measurement mechanisms such as these, organizations can identify real goals for quality improvement. (See Disparities Solutions Center [2007] for guidance in mastering this process.)

Educate Providers and Staff Effective communication across cultures is a critical component of providing quality healthcare to diverse populations and is mission critical for a successful, effec- tive, and meaningful healthcare system transformation. Healthcare professionals need a practical set of skills and tools that enable them to connect with and provide quality care to patients—anywhere, regard- less of differences in background and regardless of the length of the encounter. These skills are also needed in the delivery of team-based care, given the diversity of the healthcare workforce.

Incorporate Cultural Competence into Wellness and Disease Management Most efforts to improve quality are broadly targeted to the general population, rely- ing on a one-size-fits-all approach. These standard quality improvement (QI) initia- tives place no emphasis on addressing the unique needs of culturally diverse populations. Although the QI movement has led to significant improvement in quality overall, minority populations and other diverse groups have not benefited proportionately, such that, in many quality indicators, disparities remain the same or have even worsened (AHRQ 2008).

Culturally competent QI interven- tions are designed to improve care for everyone while paying specific attention to racial and ethnic minorities and cultur- ally diverse populations. For example, a colorectal cancer screening project was implemented at a large healthcare system to increase colonoscopy screening rates for all patients; it also included interven- tions tailored to patient groups that had a history of significantly low screening rates, including patients with language barriers. The intervention resulted in improved

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screening rates for those patients with language barriers (Green et al. 2010).

The emergence of health coaches and patient navigators and the reemergence of community health workers—all of whom have the cultural and linguistic capaci- ties to meet the needs of diverse popula- tions—^will undoubtedly be a centerpiece of healthcare system transformation that focuses on culturally competent QI. Healthcare information technology, such as remote monitoring, telemedicine, and text messaging, show great promise as well. Exhibit 2 provides a summary of rec- ommendations for improving the cultural competency of QI interventions (Green et al. 2010; Lopez et al. 2011).

In summary, even those organizations that self-identify as being fully commit- ted to healthcare equity, such as those that have participated in the DLP, can learn practical, operational lessons that contribute to their effort to improve value. Overall, the field still has a long way to go, given that, for example, the majority of DLP organizations are currently focused on building the basic infrastructure to better identify disparities and routinely reporting on their performance. More advanced work—particularly in the area of interventions—remains less common. Some may see this status as discouraging, while others may see a world of opportu- nity ahead—a chance to create a substan- tive movement characterized by progress and innovation.

T H E PURSUIT OF H I G H - V A L U E HEALTHCARE Healthcare leaders who want to consis- tently provide high-value care can draw up a common-sense, evidence-based plan that incorporates the tactics discussed in this article. Five areas in particular can

be developed to improve quality, address disparities, and achieve equity and high value, and they can be cross-implemented with the key lessons learned from the DLP (discussed earlier), all with the benefit of support from key financial drivers.

Population Management Population management will be especially critical in an environment of value-based contracting. To deliver high-value, acces- sible healthcare to diverse populations, healthcare organizations should build cul- tural competency features into the design of population management initiatives and provide the necessary training to all care team members. These roles may include nurse case managers who are multilin- gual; staff who serve as language interpret- ers; care team members who are trained to explore and manage the social and cultural context of the encounter, which may affect a patient's treatment adherence and fol- low-up; staff members who distribute and explain educational materials in multiple languages or at a common level of general and health literacy; and patient navigators who engage and empower patients using the tools of motivational interviewing, patient engagement, and shared decision making in ways that are effective across cultures.

ACOs are expected to cover diverse populations in different communities and will seek to reduce costs using pre- dictive analytics that take into account race and ethnicity, socioeconomic status, educational level, and other risk factors. Equipped with such meaningful data, organizations can develop targeted, cultur- ally competent QI interventions that not only improve quality and reduce the cost of care delivered to all patients but also have the capacity to meet the needs of

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E X H I B I T 2 Recommendations and Examples for Improving Cultural Competency of Quality Improvement Interventions

Recommendation

Identify disparities to guide interventions

Identify barriers to care for specific disparity groups

Address common barriers

Examples

Collect race/ethnicity and language data; stratify quality data; identify disparity conditions and populations

Conduct focus groups, interviews, or informal communications with patients and staff; engage communities

Communication barriers: language, general literacy, and health literacy

Provide interpreters; ensure language is concordant among providers/stafFand navigators/coaches/CHWs; provide materials written in target languages at an appropriate literacy level

Difficulty accessing and navigating the system

Simplify logistics of appointments; offer flexible hours; coordinate peer support networks and referrals; minimize costs (financial and time); employ patient navigators/ coaches/CHWs

Patient-centered, culturally competent care

Provide cultural competence training for clinicians and staff; hire culturally competent navigators/coaches/CHWs

Conscious and unconscious biases in clinical decision making

Develop evidence-based guidelines; create physician report cards stratified by race/ethnicity/language

Note: CHW = community health worker.

Source: Green and colleagues (2010) identified six major recommendations for improving cultural competency of quality improvement interventions and offered examples of how to operationalize each concept.

racial and ethnic minorities and vulner- able populations. These interventions should address the social, environmental, and behavioral determinants of health.

Measures such as these have not been fully embraced because of the pervasive focus on offering revenue-generating pro- cedures at the expense of a broader notion of public health. In the near future, how- ever, institutions that previously paid little attention to collecting meaningful data on race and ethnicity and developing cultur- ally competent QI interventions will have a financial incentive to do so, and new regu- lations will foster change in this direction.

Transitions of Care and Readmissions Improving transitions of care and prevent- ing readmissions for targeted disease popu- lations, such as patients with congestive heart failure, have attracted a lot of attention and resources since financial penalties have been put in place. Because minorities have higher readmission rates for congestive heart failure than do their white counter- parts, they require—and deserve—special attention (Rathore et al. 2003). As with population management, interventions or approaches to prevent readmissions must include accommodations to ensure that language barriers in the discharge process

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As the work in patient safety expands, healthcare

organizations must establish a culture of

accountability around safety for diverse

populations.

are addressed; any cultural perspectives that might lead to misunderstanding about medications or the care plan are assessed and addressed; mutual imderstanding about where, when, and how the patient should follow up is confirmed; and an overall strategy that takes into account the patient's social and community context is developed. Without these considerations, higher readmission rates often result, which in turn negatively affect an organization's bottom line. (Boston University Medical Center [2013] and Meducation [2013] are

two organizations that offer helpful resources related to care transitions.)

Appropriate Utilization and Avoidable Hospitalizations Ensuring that those with health insurance know how to use it and when to

use it is a daunting task already; imple- mentation of the AC A will require even more attention to helping those who have difficulty navigating the complex healthcare system. Research indicates that minorities with insurance tend to have difficulties in this area for both social and cultural reasons, resulting in the use of the emergency department for care (which may also be attributed to limited availabil- ity of primary care services, difficulty in understanding how to use primary care, or lack of convenience) and avoidable hos- pitalizations (Boston University Medical Center 2013; Meducation 2013). This issue will soon be compounded by the addition to the healthcare system of a diverse group of newly insured people who may have no experience with health insurance or with navigating the system. For a healthcare organization, developing tactics to teach

health insurance literacy in a culturally and linguistically appropriate way, link patients to primary care providers who are culturally competent, and educate patients on how to use the healthcare system effec- tively is essential to ensuring equitable ac- cess to high-value healthcare that prevents disparities, waste, and unnecessary costs.

Patient Experience Improving the patient experience has be- come a key component of healthcare quality and a major focus of healthcare organiza- tions as a result of the push for public reporting and new financial incentives to meet patients' needs and expectations. Again, research indicates that minority patients are not always proportionately rep- resented in patient experience surveys, and when they do participate in surveys, their background may influence their level of comfort with giving honest feedback. For in- stance, some racial and ethnic groups may consistently rate their experience as positive because of a cultural belief that offering criticism is inappropriate; others may tend to be overly critical because they are cultur- ally oriented to think there is always room for improvement (Goldstein et al. 2010).

To gauge the experience of diverse patient populations, we must gather their perspectives using multiple methods and take the time to reach out to them to ensure we are not leaving any voices out of the discussion. Only when we proactively seek feedback from all patients (includ- ing minority and vulnerable populations) can we tailor services to meet their needs and expectations and develop interven- tions that improve patient experience and achieve high value. To that end, we must train all healthcare professionals on how to communicate in a clear, respectful, and culturally competent way.

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Patient Safety Patient safety has drawn the most atten- tion and energy among healthcare leaders and professionals over the past ten years. We have made great progress in this area, but we still have much to do, especially concerning the safety of minority patients. Although we know that many errors experienced by minorities are due to com- munications issues, little attention is paid to effectively identifying and preventing medical errors in patients with limited English proficiency. Medication reconcili- ation, discharge instructions, informed consent, and pre/peri/postoperative in- structions, for example, have been identi- fied as high-risk scenarios that can lead to medical errors, risk management issues, and situations that have dire financial con- sequences (Betancourt et al. 2012).

As the work in patient safety expands, healthcare organizations must establish a culture of accountability around safety for diverse populations. Such a culture entails training all healthcare professionals— especially those who interact routinely vwth minority and vulnerable populations—to recognize and report near-misses and errors, institutionalizing systems that capture the demographics of patients who have experienced near-misses or errors, and identifying the root causes of these adverse events. (For more information on building a culture of accountability that ensures the safety of all patients, refer to the collaborative work of the Disparities Solutions Center, the Mongan Institute for Health Policy, Abt Associates, and the Agency for Healthcare Research and Qual- ity [Betancotirt et al. 2012].)

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CONCLUSION The drive to deliver high-value health- care to all has begun. While our goals

seem clear—to ensure access to high- quality healthcare for all, and to do so cost-effectively—the new structures for delivery, such as ACOs and PCMHs, and the tactics required to make these struc- tures successful remain works in prog- ress and a great experiment. Given this environment, healthcare organizations will look for quick wins, or areas of focus that potentially provide high returns on investment—high-value targets. Suc- cessful leaders will quickly identify these high-value targets and deploy systems and tactics to achieve them. For some areas, proven models can be deployed; for others, similar models transferred from other industries can work; and still others may need complete innovation and a new set of models.

As healthcare leaders make difficult choices, they should consider the reali- ties of healthcare equity. First, 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 evidence-based approaches is available to help leaders ad- dress healthcare inequity. There is no need to reinvent the wheel. Unequal Treatment provides a clear blueprint, and myriad other guides share insight on building sys- tems and implementing tactics for elimi- nating or minimizing disparities (see, e.g.. Disparities Solutions Center 2013). Valuable lessons can be learned from early adopters of these strategies.

Third, some observers argue that ef- forts to address racial and ethnic dispari- ties in healthcare are simply too costly in these financially challenging times and that no strong business case can be made for such an effort now. This viewpoint centers on the perception that addressing

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disparities requires significant cost outlays and yields no clear cost savings. However, evidence suggests that being inattentive to the root causes of disparities adversely affects efficiency and an organization's bottom line (Alexander et al. 1999; Jiang et al. 2005; MedPAC 2008; Rathore et al. 2003). A key part of delivering value is identifying areas of inefficiency and waste (current investments that yield no good return), and disparities are a great example of such inefficiencies and waste.

Finally, to operate and compete in the redesigned healthcare system, we must deliver high-value healthcare to a diverse patient population. The US population has become racially and culturally diverse, and the newly insured will mirror this diversity. 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 compe- tent, and high-quality care to all is well within reach.

REFERENCES Agency for Healthcare Research and Quality

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