Medicare, the national quality infrastructure, and health disparities

What can Medicare do to improve quality and reduce disparities in clinical care? Increasing the cultural competence of individual physicians and their use of evidence-based guidelines will be useful--but insufficient. What is needed are organized care management processes that will support physicians and medical teams in their clinical decision-making, assist patients in managing their own illnesses, and provide clinicians with feedback on their performance. Medicare should therefore seek to strengthen both the capabilities of medical groups to improve the quality of care and their incentives to do so. Unless carefully designed, however, incentives to improve quality--such as pay for performance and public reporting--could increase disparities, for example, by directing additional resources to providers who are already performing at a high level. Medicare should be alert to this possibility when devising incentives for quality and should carefully study the effects of incentives on disparities. If general efforts at quality improvement do not succeed in reducing disparities, targeted measures will be required.