Quality improvement efforts under health reform: how to ensure that they help reduce disparities--not increase them

Despite persistent evidence of continued racial and ethnic disparities in health care, little explicit attention has been paid to how quality improvement activities might affect disparities. As the nation focuses on the practical realities of implementing health care reform and concurrent quality improvement provisions under the Affordable Care Act of 2010, it is important to recognize that overall improvements in the US health care system might not automatically benefit all segments of the population equally. In this article we highlight challenges to ensuring that quality improvement efforts reduce racial and ethnic disparities. These include making certain that quality improvement efforts measure disparities and improvements in them, notwithstanding providers' reputational concerns; that such efforts not create perverse incentives for providers to avoid serving minority patients; that they be applied to institutions where minority patients are most likely to receive care; and that they fully engage minority patients despite language or other barriers. To assist in these efforts, we argue for the development of disparities impact assessments to measure the effect that the Affordable Care Act's quality provisions will have on reducing disparities.