High Quality Care for All: Our Quest for Equity in Health Care

Dr. Joseph Betancourt and Dr. Alexander Green, Disparities Solutions CenterAt Massachusetts General Hospital, Dr. Betancourt (pictured at left) is the director of both the Disparities Solutions Center (DSC) and Multicultural Education. He is also an associate professor of Medicine, Harvard Medical School. Of Puerto Rican descent, Dr. Betancourt grew up in a bilingual, bicultural home. As a child, he served as an interpreter for his grandmother, who didn’t speak English. He saw firsthand how language and cultural barriers contribute to patient vulnerability and low-quality care.

Dr. Green (pictured, right) is associate director of the DSC and chair of the Cross-Cultural Care Committee at Harvard Medical School. He grew up in San Diego, is bilingual and volunteered in border clinics in Mexico during medical school. Dr. Green then served two years in the National Health Service Corps, caring for a diverse patient population in a poverty-stricken, medically underserved area in Queens, New York.

Few would dispute that Massachusetts General Hospital provides the best patient care in our state, if not the country, and perhaps the world. As physicians, we are especially proud that MGH strives to deliver high-quality care to every patient, regardless their race, ethnicity or background.

Providing the Best We Have to Offer

Whether a successful businessman or woman, a construction worker, or a street cleaner; whether you are Black, White, Asian, Middle-Eastern, Latino or Native American; whether you have a PhD in English, or don’t speak or write English at all; whether you’ve been in Boston for four generations or four hours, we feel it is our responsibility to provide all with the best we have to offer. Although it may seem that all hospitals should share this commitment, MGH distinguishes itself by putting its money where its mouth is.

Unfortunately, disturbing evidence shows that certain patients — particularly racial and ethnic minorities — receive lower quality health care in hospitals, compared to others. That’s true even when they have the same health insurance, live in the same neighborhoods, and have the same level of education. Unequal Treatment, a highly influential report from our nation’s prestigious Institute of Medicine, is one of many recent studies documenting this hard-to-accept truth. Research shows that if two patients are seen by a doctor for chest pain, a minority patient may be less likely than a white patient to be referred for cardiac catheterization, angioplasty or cardiac bypass surgery. If two patients come to the emergency room with a broken arm or leg, the minority patient is likely to receive less pain medication.

The reasons for these disparities are complex. They include the fact that minority patients and their healthcare providers may have more difficulty communicating with each other. Even well intentioned heathcare providers may unintentionally make assumptions about patients that might impact treatment. Certain patients may be more mistrustful of healthcare providers, impacting their willingness to comply with recommended tests and treatments.

Ultimately, there is no one suspect and no one solution. Nor is this about blame. Just like all of our efforts in patient safety, we must strive to understand why these differences occur and do everything we can to fix them. This has attracted even more attention recently, with newer research. For example, we now know that minorities and patients with limited-English proficiency experience more medical errors with greater clinical consequences than their white counterparts.

Choosing to Be a Leader

All of this will take on greater importance for hospitals across the country as they adapt to new standards released by the Joint Commission in support of equity in health care. Efforts to reform health care and control costs also emphasize these areas.

Mass General has chosen to be a leader, not a follower on this issue. In 2003, shortly after the release of Unequal Treatment, Peter L. Slavin, MD, president, Massachusetts General Hospital, created the MGH Disparities Committee. We began our journey with a simple charge to take all necessary steps to identify, prevent and address racial and ethnic disparities in health care. Our progress has already included many successes and innovations:

  • MGH strengthened its capacity to collect accurate race, ethnicity, language and education-level data for all patients. Using this information, we developed the nation’s first Disparities Dashboard, an annual public report that monitors the quality of care we deliver. For example, we can demonstrate that anyone who has a heart attack, pneumonia or congestive heart failure receives the same, excellent care.
  • After discovering that Latinos with diabetes had poorer health outcomes, we deployed an award-winning, culturally competent coaching program to help manage diabetes treatment for patients at our Chelsea Healthcare Center. It has improved care for all diabetics.
  • We provided cultural competency training — focusing on improving communication across cultures — via an innovative e-learning tool for nearly 1,000 MGH physicians and 1,500 frontline staff.

The formation of the Disparities Solutions Center (DSC) in 2005 further cemented MGH’s commitment to improving quality, addressing disparities and achieving equity. The DSC is a multidisciplinary team of healthcare professionals whose expertise includes racial/ethnic data collection, performance measurement and disparities interventions. The DSC strives to develop new research and translate innovative findings into policy and practice. We also develop and evaluate customized policy and practice solutions for healthcare providers, insurers and other organizations and provide related education and leadership training.

Strategically Eliminating Disparities

The DSC has helped shepherd the disparities activities at Mass General, including the work of the Disparities Committee. We have conducted influential research projects, published practical guides to addressing hospital disparity issues and shared lessons learned through free, nationally-broadcasted web seminars and presentations.

The Disparities Leadership Program (DLP), launched in 2007, is a year-long education program designed for executives from hospitals, health plans and other healthcare organizations that want to strategically integrate the elimination of disparities into their organizational planning, or advance a related project, particularly through quality improvement. To date, the DLP has trained 152 participants from 74 organizations, large and small, located in 26 states, the Commonwealth of Puerto Rico and Switzerland.

Because of our personal and professional backgrounds, this work is personal for us, not just an interesting academic pursuit. We also know that successfully advancing the cause of equity in health care requires more resources than even the most committed institution can fully provide. Philanthropic support would be incredibly helpful in assuring the DSC achieves its mission. For example, it would allow us to expand our multilingual, culturally-competent health coaching and navigator programs to help vulnerable patients in the Greater Boston area better manage their diabetes, or prevent cancer. It would also give us the opportunity to provide scholarships to the DLP to public hospitals, community centers and other organizations that would benefit most from what we’ve learned and what we teach. As it is, they are rarely able to participate because of limited resources.

As Mass General concludes its bicentennial celebrations, we look back with pride at our work in equity, confident that it stands tall among the institution’s achievements. We firmly believe in the importance of delivering high-quality care to every patient we see, no matter what their background. Our ambition drives us to not only make this a continuing reality at Mass General, but everywhere across the country.