presents the overarching conceptual model for disparities that the individual papers explore in more detail. While a number of other conceptual frame-works exist (Cooper, Hill, and Powe 2002
; Jones 2000
; King and Williams 1995
; Kressin 2005
; Smedley, Stith, and Nelson 2003
; Williams, Lavizzo-Mourey, and Warren 1994
), our model is specifically designed to facilitate understanding of the diverse interventions covered in our review papers. As represented by the vertical brackets on the borders of , a patient environment and health care environment encompass everything from governmental policies to community and health care organizations. Focusing first on the central circles in the diagram, individuals go back and forth between being persons in the community and patients in a health care organization. Important events can occur in both settings that affect processes of care and outcomes. For example, providers may order a series of diagnostic tests and treatments that impact the health of patients. This medical care can affect the entire spectrum of health and illness, from preventive care to acute illness to chronic disease management. The role of the community is also critical. The bulk of patient self-management of chronic illness takes place in the community, such as monitoring symptoms, taking medications, and participating in programs of physical exercise and healthy eating. In addition, persons are surrounded by social networks of peers and families that influence attitudes and behavior, and healthy choices are influenced by environmental factors such as the availability of fruits and vegetables in the local markets.
Conceptual Model for Racial and Ethnic Disparities in Health Care
Americans’ access to health care is variable, and as demonstrated by the arrows between the community and health care organization circles, interventions that create linkages between communities and health care systems may improve access to care and subsequently improve health status. These range from national policy interventions such as the provision of adequate health insurance, to the use of community health workers or promotoras who can play liaison, case-management, cultural translation, and patient advocacy roles. Thus, community and health care organization environments exist for the individual person/patient, and there are ways to integrate these two worlds more seamlessly. Social norms, including subtle forms of racism, are suffused throughout both of these environments, represented by the overarching horizontal bracket at the top of .
Interventions in the health care organization and the larger health system are the primary focus of the Finding Answers program. Within the health care organization circle, a variety of quality improvement initiatives may lead to better delivery of care processes and ultimately better health care for minority populations. Productive communication and interaction between providers and patients are essential, and thus cultural competency programs for providers and empowerment programs that encourage patients to be more active partners in their care are examples of possible interventions. As previously noted, innovative ways to link the health care organization and community are needed.
The upper half of demonstrates that the interactions of persons with providers, health care organizations, and the community occur within wider political and economic environments. Both government and nongovernment organizations can influence health care organizations and, more indirectly, the community through payment mechanisms and the creation of standards. Payors include Medicare, Medicaid, private insurers, and managed care companies. Standards can be based on laws, regulations, or scientific evidence. Federal and state governments have an enormous impact on health through the financing, regulation, and provision of care. For example, well-designed policies that provide financial incentives to improve quality of care and reduce disparities may have benefits (Chien et al. 2007
). Nongovernmental accreditation organizations, professional bodies, and organizations focused on quality are some of the other entities that affect payors and standards.
These payors and standards, represented by boxes in the top third of , can be intermediaries linking the decisions of governmental and nongovernmental bodies to the actions of health care organizations. Payors also influence access to care. For payors, key levers affecting disparities include decisions about who pays, whom does one pay, what does one pay for, how does one pay, how much does one pay, and who has access to care and health insurance? Governmental and nongovernmental organizations can create standards that either directly or indirectly affect health disparities. For example, antidiscrimination and access to care laws such as the Civil Rights Act of 1964, the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) antidumping legislation (Centers for Medicare and Medicaid Services 2007
), and more recent interpreter and cultural competency laws may reduce disparities (Gibbs et al. 2006
; Ladenheim and Groman 2006
). Accreditation and manpower regulations such as licensure and scope of practice rules affect the supply of providers and health care facilities serving minority populations. Scientific evidence and practice guidelines by a variety of organizations set the standard of care, and thus some of the targets for the quality of care to be received by all. Decisions by states and private organizations such as the National Committee on Quality Assurance (NCQA) to publicly report quality of care data also implicitly create a standard of care that health providers will strive for (National Committee on Quality Assurance 2007
Key Domains in the Conceptual Model for Racial and Ethnic Disparities in Health Care