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\fNew models of delivery have emerged that hold promise to re duce health disparities and have been promoted by both providers and payers. For instance, the lnr stitute for Healthcare Improver ment promulgated the Triple Aim, which advocates siauultaneous improvements in patient experi ences and population health and lower cost per capita and has considerable applicability for re ductions in health care disparities.3 Furthenuore, the passage of the Patient Protection and Afordable Care Act (Pub L No. 111148, 124 Stat. 855 [March 2010]; ACA) and current elforts in payment refomi signal the beginning of a trans fonnation in health care. An entire new set of structures is being de veloped to Etcilitate increased access to care that is costrefettive and of high quality and has the potential to reduce health disparities from a population health perspective. Research eE'orts are needed to evaluate whether systelurlevel changes have signicant effect on reducing health care disparities, whether newly developed patient care models are eEecdve, and whether payerrbased changes lead to improved outcomes, including patient satisfaction. QUALITY OF CARE AN D Q UALITY | M P ROV E M E N T Quality of care received is a significant factor that contributes to health disparities. From a health disparities perspective, a signicant gap exists between the quality of care that is delivered to health disparity populations and the care that the health care system can optimally deliver.4 Understanding whether patients are receiving evidencerbased and guideliner driven care is essential for elimir nating health care disparities. Supplement 1, 2019, Vol 109, No. 51 Although, optimally, patient care should be individualized and patientrcentered, standards of care still need to reect best medical practices. Two of the most prevalent quality issues are overuse and underuse. Overuse, the provision of health care services for which hanns outweigh benets or that is not necessary, represents poor quality and contributes to higher health care costs. A better uni derstanding of overuse in the US health care system could inform eEom to reduce inappropriate care. However, evidence documenting that racial/ ethnic minorities expe rience a disproportionate overuse of care is limited in the literature and provides an opportunity for further exploration.5 Clinicians and researchers should try to uni derstand how and why health disparities might be associated with overuse and take appropriate ac tions. Do characteristics of patients lead to overuse? Clinician bias and stereotypes? Or health care system ctors? Studying overuse may provide insight to underuse, which is the failure to provide eective care. Unfortunately, undenise of eEecve health care interventions is more prevalent among uni derserved populations." Under standing why disparity populations do not receive care, especially early preventive therapies, is an impor tant inquiry to help reduce health disparities. On a similar note, under standing how care is delivered is essential to addressing health disparities. Quality improvement methods hold promise in helping health systems identify quality of care problems. These approaches are appealing for addressing disparities because they oEer a systematic way to study care delivery and a method for tai loring or changing an inter vention over time based on continuous data monitoring. AJPH Yet disparitiesrfocused quality improvement remains under studied, with limited attention to core methodologies and outcome measures. Examples in the literature of quality ink provement interventions afr fecting disparities are relatively scarce and reect a nascent eld,7 but national studies have reported that racial/ ethnic disparities have been largely eliminated in the quality of hospital care for Medir care beneficiaries and in the cone trol of hypertension, diabetes, and hyperlipidemia in some Medicare Advantage health plans through quality monitoring and improvement processes\") Fur thermore, the Health Center Program funded by the Health Resources and Services Admin istration provides care for nearly 26 million of the nation's most vulnerable populations. Health centers improve health outcomes by emphasizing the care mane agement of patients with multiple health care needs and the use of key quality improvement practices, including health inf formation technology. In 2016, nearly all health centers showed improvement on 1 or more clinical quality measures, inf cluding exceeding the national average in key diabetes and by per-tension 111easures.m Although quality improvement efforts have focused on Medicare and care delivered in federally qualied health centers, efforts are needed to understand how quality imr provement tools can be used eff fectively to reduce health care disparities in all health plans and systems. PAYMENT REFORM SYSTEMS In 2014, the ACA was eur acted and became a legislative Wesserman et 01'. ETIOLOGY SCIENCE intervention that many believed would be a significant advance ment for addressing health disr parities by improving individual health and, ultimately, popular tion health. The ACA refers to 2 separate pieces of legislationithe Patient Protection and Aiordr able Care Act (Pub L No. 111 148) and the Health Care and Education Reconciliation Act of2010 (Pub L No. 111152)7 that together expand Medicaid coverage to millions of lowr income Americans and malte numerous improvements to both Medicaid and the Children's Health Insurance Program. The ACA aimed to refonu how in surance and health systems work to improve health care access, quality, and individual and public cost. Since these coverage prof visions took effect in 2014, uninsured rates have decreasedi from 22.3% in 2010 to 12.1% in 2017.11 Uninsured rates declined most sharply among the poor or nearpoor and among Latino, Black, and Asian individuals. Be cause lack of health care access and insurance coverage are major factors that help perpetuate health disparities, this increase in inf surauce coverage has signicant potential to reduce access barriers. With the passage and impler mentation of the ACA, a cone siderable number of research opportunities emerged. It is rear sonable to expect that the ACA will directly affect health disparity populations who historically have experienced lower coverage rates and suboptimal access to care.12 Perhaps one of the most imr portant unanswered questions might be whether the ACA would lead to more equitable and efcient health care in the long temt. Although the ACA pro vides a first step in ensuring ac cess, how large an effect it will have on disparities in care and Peer Reviewed Analytic Essay 565 ETIOLOGY SCIENCE outcomes will be influenced by the repeal of the individual mandate provision as part of the recently passed taxrcut bill and other possible legislative efforts to modify, repeal, or replace it. Even if the ACA continued uni changed, more longrterm data are needed to evaluate the potential effect on health care disparities. The ACA and subsequent legr islation, including the Improv ing Medicare PostrAcute Care Transforntation Act of 2014 and the Medicare Access and Chile dren's Health Insurance Program Reautliorizrtion Act of2015, have empowered the Centers for Medir care and Medicaid Services to implement valuerbased programs. Public and private payers also are developing altemative payment models to encourage providers to integrate care and be accountable for both the quality and the cost of patient care. 1 1' Examining payment refomi as a tool to achieve equity has not been well studied. Sysr tematic reviews of payforper fon'nance initiatives indicate that few have been explicitly designed to reduce disparities, and general payrforrperfomiance incentives have often Failed to reduce disr panties. \"'15 Although payrforr perfomian ce programs can increase quality of care and decrease costs, they also may result in unintended consequences. For example, health systems that serve numerous pa tients with preexisting health cone ditions that require considerable care and expenditure may not meet perfomiance goals and would be penalized rurder these progranrs. When outcomes depend on both dinicians and patients, provider inputs may diEer according to patient needs, with implications for reimbursement. 16 Several studies have shown that larger hospitals, teaching hospitals. and safetynet hospitals, which traditionally serve disadvantaged patients, are more likely to rank poorly on quality 566 Analytic Essay Peer Renewed measures and therefore are more likely to be penalized under pay forrperfonnance progranrs than hospitals that do not typically serve these patientsm The Medicare Accountable Care Organization (ACO) prof gram is designed to help reduce cost while improving quality of care for Medicare beneficiaries. Although the ACO program encourages delivery system in tegration and quality improver ment, which may benet underserved populations who of: ten receive care from clinicians and systems with limited resources, co ncems similar to those for pay for perfonnance have emerged.'7 ACOs support consolidation of physicians into larger organizations that may provide enhanced struc tural capacity for care coordination and quality improvement but it is not yet clear whether ACOs result in reductions of health disparities, and this knowledge gap presents a unique opportunity for health services research. Similarly, Med iCaid ACOs have been established in 12 states, with several other states pursing this option. These Medicaid ACOs seek to drive accorurtability through 3 key ace tivities: (l) implementing a valuer based payment structure, (2) ureasuring quality improvement, and (3) collecting and analyzing data. As with Medicare ACOs, understanding the risks and bener ts of this payment refonn system with regard to the elimination of health disparities warrants further studyl PATI ENTeCENTERED M E D I CA L H O M E Recently, the patientrcentered medical home (PCMH) has been endorsed by maj or primary care organizations and in the ACA as a model with the potential to refonn Wasserman 2t til. the US health care delivery system and reduce disparities in health care. As defined by the Agency for Healthcare Research and Quality, the PCMH amework has 5 attributes: comprehensive care, patientrcentered care, cor ordinated care, accessible services, and quality and safety.\" Although the model is still evolving itaims to improve access to care (e.g., through extended oice hours and increased communication bee tween clinicians and patients) while simultaneously reducing costs?\" Ideally, a PCMH model should include a health equity dimension that addresses the social de terminants of health in a dened population. Many stakeholders in PCMH initiatives believe that an effective primary Care system that promotes preventive care and of: fers conmiuuityrbased services has the potential to advance overall quality of care while reducing health disparities.2| However, proliferating PCMH initiatives over the past decade have provided little empirical evidence on the effect of the PCMH on reducing health disparities and confronting health inequity. One option to consider is to create an equity metric in evaluating quality of care in health systems. A challenge for researchers is how to best measure various PCMH models in temts of providing optimal health care and also reducing health disparities. Opportunities for rrther research into how PCMH models can we duce disparities include research studies that evaluate systemrbased approaches, teambased care, and evidencerbased interventions. PATI ENTeCLINICIAN INTERACTION As the United States becomes more diverse, it is important to understand how culture inf uences care and contributes to health disparities. Some examples of where cultural competence may reduce quality of care include a mismatch between the biomedical approach to health and disease and the health beliets and practices of racial/ethnic minority populations, such as those related to illness causation, holistic views of mind and body, the prioritization of symptom management versus disease cure, and family in volvement in medical decisionr making.22 Lack of appreciation or awareness on the part of clinicians of patient knowledge, beliefs, or communication styles or of their own biases can result in poor par tienteclinician communication with ratial/ ethnic minority pa tients. This can be characterized by less patientrcentered cornmuuicar tion, less discussion of trealanent options, and less positive and more disengaged nonverbal behavior by clinicians.23 Poor patientclinician communication is associated with disparities in outcomes for chronic diseases and pain management and in patient satisfaction with care.24 Health care systems have started to address cultural competence and have adopted dilferent approaches and techniques to improve out comes and reduce health disparities. Some of these approaches and techniques improve the knowledge and attitudes of health professionals and promote satisrction with care25 but they have not been clearly shown to improve health outcomes.26 More evidence and better data are needed to illustrate defu'iitively how to deliver culttu ally competent care. Similarly, additional research is needed to unpack the construct of culturally competent care and to Iuiderstand the contribution of its different components, including those that are not strictly \"cultural," to disparate health outcomes. For example, cultural competency AJPH Supplement 1, 2019, Vol 109, No. 51 training for clinicians generally for cuses on cultural belie, practices, and communication styles of racial/ ethnic minority populations, often to the exclusion of other social detemiinants of health, such as poverty, unhealthy living environr merits, psychosocial stressors, and racism and discrimination. Such narrowly defined interventions to improve cultural competency may have limited benet in the reduction of health disparities. The number of individuals with limited English prociency in the United States has risen dramatically over the past several decades. An estimated ()0 million individuals in the United States speak a primary language other than English, and more than 42% have limited Enr glish prociency.27 Language barriers encountered in health care have a negative effect on patients with limited English prociency and are associated with fewer cli nician encounters and prevenr tive services, less treatment comprehension, poor adherence to prescribed treatment, lower satisction with services, and more adverse EVEHB.27'2H Although inf terpreter services have been prm moted as a means to overcome language barriers and are part of the National Standards for Culturally and Linguistically Appropriate Services, they are not fully used by the health care system because of cost and other logistical con, straints. Subsequently, clinicians need to better understand how to best deliver linguistically appror priate services to patients with limited English prociency to ensure that they receive patient centered care. CLINICAL DECISION? MAKING Another area that is gaining attention and has been identied Supplement 1, 2019, Vol 109, ND. 51 as contributing to health care disparities is clinical decision making, especially when guide, lines have not been tailored for racial/ ethnic groups. Tailoring treatment regimens for racial/ ethnic groups is an accepted fonn of practice and often takes into account behavioral change mes sages, communication styles, and possible dnig responsiveness that might be explained by genetic variation.\" However, guidelines historically have been established on the basis ofhomogeneous populations.\" Population differ ences with potential pathor physiological and therapeutic implications may be obscured by standards. For instance, data from the Nurses' Health Study show that Asian women had more than double the risk for developing type 2 diabetes than did White women of the same body mass index.31 This diEerence has not yet been clearly explained, but data also show that when compared with White persons of similar body mass index, Asian persons have more total body fat. It has been suggested that lower cutoff points for body mass index and abdominal obesity metrics should be used for Asian persons, which may inuence decisions to screen for diabetes, for example.32 Physiological and therapeutic needs that are obscured by existing standards Can contribute to health disparities. lnadequately tailored health care also can lead to disparities in health outcomes. New research is needed to exr plore how clinicians make medical decisions based on guidelines for their patients. Findings from these studies can provide an understanding of when and how current standards of care may contribute to health disparities. The ndings ' so may infoml efforts to improve guidelines, screening, and criteria so that they take into account AJPH characteristics ofdiverse pope ulations, as well as efforts to ensure that the transition to perr sonalized medicine approaches adequately accounts for characr teristics of populations and diverse individuals. STEREOTYPE, BIAS, AND STIGMA As noted earlier, health care disparities are not fully explained by lack ofaccess and health inf surance. In fact, health care disr parities often persist among populations covered by health insurance, although they are \"10\": pYOnOIIHCCd anlong pere sons who lack health insurance or live in areas with high levels of poverty. Stereotyping, stigma, biases, and uncertainty on the part of clinicians can contribute to unequal treatment of patients, as can care that is poorly matched to the needs of underserved patients. Disparities also may emerge from patientrlevel face tors. For example, minority pa tients may be more likely to decline recommended services, adhere poorly to treatment regr imens, and delay seeking care for symptoms.\" Studies are needed to better understand how clinir cians and patients interact in the health care setting that may result in generating or reducing health care disparities. In its Um'qmzl' Trr'rrtmcutreport, the [0M identied health care clinician bias, stereotyping, and clinical uncertainty as factors that likely contribute to health care disparities.' Studies identied in this report, as well as more recent studies, provide evidence that clinicians hold implicit bias ' as well as attitudes and beliefs about racial/ethnic groups that can in, uence health care delivery. In a review of published articles, Wusserman 9t 0!. ETIOLOGY SCIENCE ndings indicate that implicit (unconscious) bias about Black, Latino, and darkeskinned irir dividuals was present among health care professionals of diff ferent specialties, training, and experience.33 Of the 15 reviewed studies, Hall et al.33 found that 14 identied implicit bias about racial/ethnic groups. Other studies have found that clinicians treat and diagnose disorders in patients from racial/ ethnic mir nority groups differently and inf volve these patients less often in decisionmaking compared with White patientsju' Overall, such interactions may contribute to a lack of trust and commitment on the part of the patient, leading to poor treatment adherence. The lOM's Unequal Treatment report suggested that health care professionals use stereotypes as an investigative or cognitive shortr cut to develop treatment plans.I Furthennore, treatanent disparr ities appear to be greater when clinicians engage in procedures for which standards of care are 35 The exact not well established. mechanisms by which stereor types and biases result in di'ep ences in clinical treatment and referral or the degree to which they lead to health disparities is not well understood. However, a model of implicit bias suggests that bias can affect clinical de cisions directly and also can affect treatment through its e'ects on interpersonal communication.37 A growing body of research suggests that experiences of stigma are associated with poor engagement in clinical care and adverse clinical outcomes. However, the e'ects of stigma and discrimination in health care settings on patientclinician interactions are not well uni derstood. A potentially uitil avenue of research is to better understand the social and stnicr tural barriers that drive disparities PeErReviewed Analytic Essay 567 ETIOLOGY SCIENCE within the health care systerrr so that engagement in prevention, care, and treatnreut ofillnesses in all individuals can be facilitated. ROLE OF PATIENT PREFERENCES Patient preferences have been hypothesized as another causal pathway for health disparities.38 Although patient preferences are nreasured differently across disr ciplines, the decisionrmaking literature denes preferences as patients' valuations of specific health outcomes. The literature has docunrerrted that patient preferences are inuenced by a considerable number of factors, including trust about medical advice, potential complicar tiorrs and negative outcorues, pain and discomfort, and misr perceptionsl'\" Basic research about patient preferences and values in minority populations is very limited, and thus nrost decisionmaking algorithms have never considered these. ln addir tiorr, only a few studies have explicitly investigated the link between patient preferences and their contribution to health disr panties.\" Of those that have, the evidence is mixed as to whether patient preferences are inuential. Understanding how patient preferences among mir nority populations infon'n health care seeking and adherence is important, especially for early diagnosis and better disease management, and presents unique opportunities for health services researchers. Quantifying how rrruch pa tient preferences contribute to health disparities will be difficult, especially because they are often entangled with other health care factors that have been identied as also contributing to health disparities. For instance, stereor typing by health care prof fessionals can lead to withholding of information and treatment on the basis of assumptions that certain groups do not wartt to undergo specific types oftreatr ruent or need an authoritative recommendation without exr planatiorr of choices. This pref vents patients from expressing their preferences around care and irraking informed decisions.\" Research on several other isr sues also could potentially yield valuable insights. For example, exploring the differences between patient preferences that are grounded in personal beliefs about ruedical treatment and those that arise from wrongly held percepr tions could help clinicians un derstand why patients express the preferences that they do. Research that examines whether preferences are shaped by lived experiences of individuals, esper cially when perceptions may ref flect the actual outcomes of care received in underserved come munities, or whether they can be modified by education and outr reach can provide infom'tation to influence the ways in which clir nicians provide counseling to their patients. CONCLUSIONS Disparities in health care pose significant moral and ethical die lemmas and result in excess health care expenditures. Un derstanding why health care disparities occur and how they contribute to populationrlevel health disparities is essential so that nrore effective equityr promoting interventions in health care systems can be impleruented and reductions in health disparities can be ultir mately achieved. Payers, systems, and communities must work together with clinicians and par tients to identify the causes of disparities in health care. In adequate, inaccessible, and lowr quality nredical care is uni acceptable. Although national ebrts such as the ACA and payment refomr can provide a springboard to address disparities, nruch ofthe eon will need to be conducted at the regional level. No single solution will eliminate health care disparities. In addition to national policy changes, local health care systems need local solutions. Health systems must commit to tracking equity mear sures, implementing quality imr provenrent initiatives, building a culturally competent health care system, and fostering and enr couraging better relationships between clinicians and patients. Although attention to health care disparities has increased over the past 2 decades, considerable knowledge gaps still exist, and greater consensus is needed on what should be done to reduce these disparities. The box on page 568 summarizes some of the leading research opportunities that emerged rom the science visionr ing process. Although some of the research opportunities are not novel and have been promoted and advocated by marry, considr erable gaps in knowledge still exist surrounding these opportunities. Overall, considerable work is still needed to understand why health care disparities occur and to iden solutions. For health equity to be achieved, it is essential to create a health care system that provides access, removes barriers to care, and provides equally eEecve HEALTH SERVICES RESEARCH OPPORTUNITIES TO ELIMINATE HEALTH CARE DISPARITIES: NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES SCIENCE VISIONING INITIATIVE more broadly. 9??P'F'P" 1. Evaluate how newly developed patient care models affect health care disparities. Examine patient preferences and how they contribute to health disparities. Evaluate the effect of legislative changes on access to and quality of care received by health disparity populations. Identify patterns of underuse and overuse of health care and how inappropriate care can lead to health disparities. Understand how current standards of care and guidelines may contribute to health disparities. Develop a comprehensive understanding of how to deliver culturally competent care in health care settings. 2. Incorporate and evaluate quality improvement initiatives to reduce health care disparities in health systems and show how they can be disseminated and implemented Examine the effect of payerbased changes on improving health outcomes and patient satisfaction among health disparity populations. $68 Analytic Essay Peer REVIewed Wusserman et at. AJPH Supplement 1, 2019, Vol 109, No. St ETIOLOGY SCIENCE treatment to all persons living in 9. Trivedi AN, Nsa W, Hausmann LRM, 21. Reibling N, Rosenthal MB. The 33. Hall WJ, Chapman MV, Lee KM, the United States. APH et al. Quality and equity of care in U.S. hos- (missed) potential of the patient-centered et al. Implicit racial/ethnic bias among pitals. N Engl J Med. 2014;371(24):2298-2308. medical home for disparities. Med Care. health care professionals and its influence CONTRIBUTORS 10. Health Resources and Services Ad- 2016;54(1):9-16. on health care outcomes: a systematic All authors contributed equally to the ministration, Health Center Program 22. LoPresti MA, Dement F, Gold HT. review. Am J Public Health. 2015; 105(12): conceptualization and writing of this Health Center Data & Reporting. End-of-life care for people with cancer e60-e76. article. Rockville, MD: Health Resources and from ethnic minority groups: a systematic 34. Gordon HS, Street RL Jr, Sharf BF, Services Administration; 2017. Available review. Am J Hosp Palliat Care. 2016;33(3): Souchek J. Racial differences in doctors' at: https://bphc.hrsa.gov/datareporting/ 291-305. information-giving and patients' partici- ACKNOWLEDGMENTS index.html. Accessed February 25, 2018. pation. Cancer. 2006;107(6):1313-1320. This article resulted from a National In- 23. Wilder JM, Oloruntoba OO, Muir AJ, stitute on Minority Health and Health 1 1. Cohen RA, Martinez ME, Zammitti E. Moylan CA. Role of patient factors, 35. Siminoff LA, Graham GC, Gordon Disparities (NIMHD)-led workshop, in Health Insurance Coverage: Early Release of preferences and distrust in health care and NH. Cancer communication patterns and cluding external experts, that examined Estimates From the National Health Interview access to liver transplantation and organ do- the influence of patient characteristics: he etiology of health disparities. Survey, January-March 2017. Hyattsville, MD: nation. Liver Transpl disparities in information-giving and af- The authors wish to thank Kirsten National Center for Health Statistics; 2017. 24. Diette GB, Rand C. The contributing fective behaviors. Patient Educ Couns. Bibbins-Domingo, PhD, MD, and Regina 12. Sealy-Jefferson S, Vickers J, Elam A, 2006;62(3):355-360. role of health-care communication to James, MD, for their contribution to the Wilson MR. Racial and ethnic health health disparities for minority patients 36. Dovidio JF, Penner LA, Albrecht TL, NIMHD Science Vision workshop. We also disparities and the Affordable Care Act: a with asthma. Chest. 2007;132(5, supply: Norton WE, Gaertner SL, Shelton JN. would like to thank Eliseo J. Perez-Stable, status update. J Racial Ethn Health Dis- 302S-809S. Disparities and distrust: the implications of MD, for his insightful review of this article. parities. 2015;2(4):583-588. 25. Sequist TD, Fitzmaurice GM, Mar- psychological processes for understanding 13. DeMeester RH, Xu LJ, Nocon RS, shall R, et al. Cultural competency racial disparities in health and health care. Soc Sci Med. 2008;67(3):478-486. CONFLICTS OF INTEREST Cook SC, Ducas AM, Chin MH. Solving training and performance reports to im- The authors do not have any financial or disparities through payment and delivery prove diabetes care for Black patients: a 37. Blair IV, Steiner JF, Havranek EP. other competing interests to declare. system reform: a program to achieve cluster randomized, controlled trial. Ann Unconscious (implicit) bias and health health equity. Health Aff (Millwood). 2017; Intern Med. 2010;152(1):40-46. disparities: where do we go from here? 36(6):1133-1139. HUMAN PARTICIPANT 6. Horvat L, Horey D, Romios P, Kis- Perm J. 2011;15(2):71-78. PROTECTION 14. Mendelson A, Kondo K, Damberg C, Rigo J. Cultural competence education 38. Katz JN. Preferences, disparities, Institutional review board approval was et al. The effects of pay-for-performance for health professionals. Cochrane Database and the authenticity of patient choices. not required for this article because no programs on health, health care use, and Systev. 2014;(5):CD009405. 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Supplement 1, 2019, Vol 109, No. S1 AJPH Wasserman et al. Peer Reviewed Analytic Essay S69