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Racial disparities in health status and healthcare have been documented for decades, yet the exact causes of these disparities are unknown. It is known that an array of factors including personal risk, interaction with the physical and social environment in communities, and interaction with the healthcare system influence health status. Efforts to eliminate health disparities will not succeed unless they include multiprong approaches focusing on the multiple levels of causation. Much attention has been paid to causes of healthcare disparities that operate primarily at the level of the individual and emphasize personal behaviors and individuals’ access to and experience in the healthcare system. In addition, the role of individual healthcare providers’ biased attitudes, stereotyping, and discrimination toward people of color, is often offered as an explanation of healthcare disparities. Barriers to accessing care and poorer quality of healthcare for minority populations have also received significant attention.

Performance incentive programs—in the form of pay-for-performance and public reporting—are receiving national and international attention. This chapter defines these programs and describes their basic features. It then outlines potential mechanisms by which these programs may impact racial and ethnic disparities in healthcare in a neutral, narrowing, or widening manner. It goes on to review the small body of literature evaluating whether performance incentive programs work, and the even smaller literature regarding how they impact disparities. It finds that performance incentive programs do not necessarily work, and that they can negatively impact disparities. The chapter then considers how particular aspects of program design should be approached with disparity-reducing goals in mind and provides a list of recommendations. It advocates that programs and research evaluate incentive programs for their intended effect, as well as for their unintended effect on disparities. Performance incentive programs are in their infancy—testing whether and how they impact racial and ethnic minorities will promote the design and implementation of programs that eliminate disparities as a part of raising quality.

Adding insult to injury. This well-worn phrase redounds with new significance when considering healthcare disparities in the context of social inequalities in health. The very same social groups at greatest risk of being subjected to inadequate access to and unequal treatment in healthcare also endure the greatest risk of poor health status and premature mortality, reflecting the daily toll of discrimination, economic deprivation, political marginalization, and prioritization of economic gain over human needs (–). Greater need and lesser care nefariously combine to create even more onerous burdens of preventable suffering, for it is within the very same bodies that these injuries and insults are integrated and embodied ().

Thirty-three years ago, the author founded an organization consisting primarily of African American cardiologists, and named it the Association of Black Cardiologists (ABC) at its inaugural meeting in Dallas, TX. The author was joined in this effort by about 12 other cardiologists attending the annual scientific sessions of the American Heart Association, and all of them agreed that the cardiovascular needs of blacks were unmet and were not being adequately addressed by the American Heart Association, the American College of Cardiology, and other prominent medical groups. Considering high blood pressure as an example, despite the fact that it was recognized that this cardiovascular disease disproportionately affected the African American population, little was being done to increase awareness of this fact or to bring blacks to medical attention for treatment of this devastating disease. In addition, stroke, often a consequence of hypertension, was uncontrolled and was having destructive effects in blacks; and coronary heart disease was not generally believed to be an important cause of illness in this population, although most black cardiologists believed that it was. They were also concerned about the shortage of African Americans trained to treat cardiovascular disease, and one of the mandates was and is to spur efforts to increase the number (at that time, it was estimated that there were only a few dozen black cardiologists in the country compared with thousands of predominantly white cardiovascular specialists, and they could count only eight fellows in training programs).

Asthma is a common chronic health condition that disproportionately affects low income people and people of color. The prevalence and morbidity of asthma in the United States have increased dramatically in the past two decades and remain high (). Relative to wealthier and white populations, disadvantaged populations have higher asthma prevalence and experience more severe impacts such as severe attacks leading to emergency department visits and hospitalizations (–). Two recent publications summarize the disproportionate asthma morbidity found among black, Native American, and some Latino populations (,). Non-Hospanic blacks and American Indians of all ages had current asthma prevalence 30% higher than non-Hispanic whites in 2002 (). The emergency department visit rate among blacks was 380% higher than that among whites, the hospitalization rate was 225% higher, and the mortality rate was 200% higher ().

The goal of Florida Healthy People 2010 is to educate professionals, culturally and linguistically, about methods to reduce the negative health consequences that impact racial and ethnic cultures. Opportunities and barriers to achieving this goal, and potential partners, have been identified. It was concluded, in the Florida Department of Health December 2004 Florida Healthy People 2010 Program Implementation Report, that the support of minority physician networks (MPNs) is necessary to achieve the Florida Healthy People 2010 goal of reducing healthcare disparities. The MPNs consist of “practitioner-experts” who are the vanguard against the health conditions found in minority, underserved communities wherein valuable experience, insights, and guidance might be gained and shared. Many physicians interested in accessing statewide initiatives also want to link service training to minority neighborhoods. The Access Health Solutions’ (AHS’) MPN recognizes that these initiatives are currently in place and facilitates a vital link between the Department of Health and the Agency for Health Care Administration (AHCA), the latter of which contractually administers the services provided by the MPNs.

This manuscript will describe the evolution of a unique community model in Mecklenburg County, North Carolina, designed to provide educational empowerment to the healthcare consumer around the area of health disparities. The model has also effectively raised the level of awareness of the social responsibility of the healthcare delivery system to hold itself accountable in the provision of equity in healthcare. This community model brings together all stakeholders in the healthcare delivery and consumer equation, around a common goal of communal stewardship, emphasizing community and corporate obligation and responsibility.

The elimination of racial and ethnic disparities in has become a national priority in the United States (). These disparities have many causes and potential solutions. In the landmark report, the Institute of Medicine reviewed and highlighted racial and ethnic disparities in healthcare as an important factor contributing to disparities in health outcomes (). This report concluded with a strong call for action to eliminate racial and ethnic disparities in the US healthcare system. Since 2003, the federal government has issued an annual National Healthcare Disparities Report to monitor racial, ethnic, and socioeconomic disparities in access to care and quality of care. Whereas the initial report released by the federal Department of Health and Human Services generated considerable controversy and debate about the content and interpretation of key findings (), subsequent reports have become a useful tool for tracking national trends in disparities across a wide array of quality measures. In 2004, this report found that lower quality of care was experienced by African Americans for two-thirds of measures, by Hispanics for one-half of measures, and by American Indians/Alaskan Natives for one-third of measures ().