[Skip to Content]
[Skip to Content Landing]
Download PDF
Table 1. 
Key Tasks and Challenges in Caring for Socially Disadvantaged Patients
Key Tasks and Challenges in Caring for Socially Disadvantaged Patients
Table 2. 
Caring for Socially Disadvantaged Patients Under the Current System
Caring for Socially Disadvantaged Patients Under the Current System
Table 3. 
Patient-Centered Medical Home Model for Socially Disadvantaged Patients
Patient-Centered Medical Home Model for Socially Disadvantaged Patients
1.
Frohlich  KLPotvin  L Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health 2008;98 (2) 216- 221
PubMed
2.
Aday  LA At Risk in America: the Health and Health Care Needs of Vulnerable Populations in the United States.  San Francisco, CA Jossey-Bass Publishers1993;
3.
Shi  LStevens  GD Vulnerable Populations in the United States.  San Francisco, CA Jossey-Bass2005;
4.
Mechanic  D McAlpine  DDRosenthal  M Are patients' office visits with physicians getting shorter? N Engl J Med 2001;344 (3) 198- 204
PubMed
5.
Braddock  CH  IIIEdwards  KAHasenberg  NMLaidley  TLLevinson  W Informed decision making in outpatient practice: time to get back to basics. JAMA 1999;282 (24) 2313- 2320
PubMed
6.
Tai-Seale  M McGuire  TGZhang  W Time allocation in primary care office visits. Health Serv Res 2007;42 (5) 1871- 1894
PubMed
7.
Burt  CW McCaig  LFRechtsteiner  EA Ambulatory medical care utilization estimates for 2005. Adv Data 2007;388 (388) 1- 16
PubMed
8.
Yarnall  KSPollak  KIØstbye  TKrause  KMMichener  JL Primary care: is there enough time for prevention? Am J Public Health 2003;93 (4) 635- 641
PubMed
9.
Østbye  TYarnall  KSKrause  KMPollak  KIGradison  MMichener  JL Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3 (3) 209- 214
PubMed
10.
Farber  JSiu  ABloom  P How much time do physicians spend providing care outside of office visits? Ann Intern Med 2007;147 (10) 693- 698
PubMed
11.
Braddock  CH  IIIFihn  SDLevinson  WJonsen  ARPearlman  RA How doctors and patients discuss routine clinical decisions: informed decision making in the outpatient setting. J Gen Intern Med 1997;12 (6) 339- 345
PubMed
12.
Tarn  DMHeritage  JPaterniti  DAHays  RDKravitz  RLWenger  NS Physician communication when prescribing new medications. Arch Intern Med 2006;166 (17) 1855- 1862
PubMed
13.
Tarn  DMPaterniti  DAHeritage  JHays  RDKravitz  RLWenger  NS Physician communication about the cost and acquisition of newly prescribed medications. Am J Manag Care 2006;12 (11) 657- 664
PubMed
14.
Blankfield  RPGoodwin  MJaen  CRStange  KC Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices. J Urban Health 2002;79 (2) 173- 185
PubMed
15.
Bierman  ASLawrence  WFHaffer  SCClancy  CM Functional health outcomes as a measure of health care quality for Medicare beneficiaries. Health Serv Res 2001;36 (6, pt 2) 90- 109
PubMed
16.
Mercer  SWWatt  GC The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med 2007;5 (6) 503- 510
PubMed
17.
Schoenborn  CAVickerie  JLPowell-Griner  E Health characteristics of adults 55 years of age and over: United States, 2000-2003. Adv Data 2006;370 (370) 1- 31
PubMed
18.
Zahran  HSKobau  RMoriarty  DGZack  MMHolt  JDonehoo  R Health-related quality of life surveillance–United States, 1993-2002. MMWR Surveill Summ 2005;54 (4) 1- 35
PubMed
19.
Schnittker  J Social distance in the clinical encounter: interactional and sociodemographic foundations for mistrust in physicians. Soc Psychol Q 2004;67 (3) 217- 235
20.
Lantz  PMLynch  JWHouse  JS  et al.  Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors. Soc Sci Med 2001;53 (1) 29- 40
PubMed
21.
Centers for Disease Control and Prevention, Prevalence of fruit and vegetable consumption and physical activity by race/ethnicity: United States, 2005. MMWR Morb Mortal Wkly Rep 2007;56 (13) 301- 304
PubMed
22.
Adelmann  PK Mental and substance use disorders among Medicaid recipients: prevalence estimates from two national surveys. Adm Policy Ment Health 2003;31 (2) 111- 129
PubMed
23.
Dougherty  RHfor the American College of Mental Health Administration, Reducing disparity in behavioral health services: a report from the American College of Mental Health Administration. Adm Policy Ment Health 2004;31 (3) 253- 263
PubMed
24.
Baker  DWWolf  MSFeinglass  JThompson  JAGazmararian  JAHuang  J Health literacy and mortality among elderly persons. Arch Intern Med 2007;167 (14) 1503- 1509
PubMed
25.
Paasche-Orlow  MKParker  RMGazmararian  JANielsen-Bohlman  LTRudd  RR The prevalence of limited health literacy. J Gen Intern Med 2005;20 (2) 175- 184
PubMed
26.
Karliner  LSPerez-Stable  EJGildengorin  G The language divide: the importance of training in the use of interpreters for outpatient practice. J Gen Intern Med 2004;19 (2) 175- 183
PubMed
27.
Weech-Maldonado  RMorales  LSElliott  MSpritzer  KMarshall  GHays  RD Race/ethnicity, language, and patients' assessments of care in Medicaid managed care. Health Serv Res 2003;38 (3) 789- 808
PubMed
28.
Kurtz  SSilverman  JBenson  JDraper  J Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides. Acad Med 2003;78 (8) 802- 809
PubMed
29.
Lott  B Cognitive and behavioral distancing from the poor. Am Psychol 2002;57 (2) 100- 110
PubMed
30.
Cooper  LARoter  DLJohnson  RLFord  DESteinwachs  DMPowe  NR Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003;139 (11) 907- 915
PubMed
31.
van Ryn  MBurke  J The effect of patient race and socioeconomic status on physicians' perceptions of patients. Soc Sci Med 2000;50 (6) 813- 828
PubMed
32.
Carrillo  JEGreen  ARBetancourt  JR Cross-cultural primary care: a patient-based approach. Ann Intern Med 1999;130 (10) 829- 834
PubMed
33.
Fiscella  KFranks  PClancy  CM Skepticism toward medical care and health care utilization. Med Care 1998;36 (2) 180- 189
PubMed
34.
Rosen  ABTsai  JSDowns  SM Variations in risk attitude across race, gender, and education. Med Decis Making 2003;23 (6) 511- 517
PubMed
35.
Schillinger  DPiette  JGrumbach  K  et al.  Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163 (1) 83- 90
PubMed
36.
Jacobs  EChen  AHKarliner  LSAgger-Gupta  NMutha  S The need for more research on language barriers in health care: a proposed research agenda. Milbank Q 2006;84 (1) 111- 133
PubMed
37.
Miller  MJDegenholtz  HBGazmararian  JALin  CJRicci  EMSereika  SM Identifying elderly at greatest risk of inadequate health literacy: a predictive model for population-health decision makers. Res Social Adm Pharm 2007;3 (1) 70- 85
PubMed
38.
Betancourt  JRCarrillo  JEGreen  AR Hypertension in multicultural and minority populations: linking communication to compliance. Curr Hypertens Rep 1999;1 (6) 482- 488
PubMed
39.
Briesacher  BAGurwitz  JHSoumerai  SB Patients at risk for cost-related medication nonadherence: a review of the literature. J Gen Intern Med 2007;22 (6) 864- 871
PubMed
40.
Bach  PBPham  HHSchrag  DTate  RCHargraves  JL Primary care physicians who treat blacks and whites. N Engl J Med 2004;351 (6) 575- 584
PubMed
41.
Fiscella  K Eliminating disparities in health care through quality improvement. Williams  REliminating Healthcare Disparities in America Beyond the IOM Report. Totowa, NJ Humana Press2007;
42.
Chin  MHWalters  AECook  SCHuang  ES Interventions to reduce racial and ethnic disparities in health care. Med Care Res Rev 2007;64 (5) ((suppl)) 7S- 28S
PubMed
43.
Trivedi  ANZaslavsky  AMSchneider  ECAyanian  JZ Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353 (7) 692- 700
PubMed
44.
Hertz  RPUnger  ANCornell  JASaunders  E Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med 2005;165 (18) 2098- 2104
PubMed
45.
Kaplan  RCBhalodkar  NCBrown  DLWhite  JBrown  EJ  Jr Differences by age and race/ethnicity in knowledge about hypercholesterolemia. Cardiol Rev 2006;14 (1) 1- 6
PubMed
46.
Pancioli  AMBroderick  JKothari  R  et al.  Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998;279 (16) 1288- 1292
PubMed
47.
Ribisl  KMWinkleby  MAFortmann  SPFlora  JA The interplay of socioeconomic status and ethnicity on Hispanic and white men's cardiovascular disease risk and health communication patterns. Health Educ Res 1998;13 (3) 407- 417
PubMed
48.
Administration for Children and Families, US Department of Health and Human Services, Temporary Assistance for Needy Families (TANF): Seventh Annual Report to Congress.  Washington, DC US Dept of Health and Human Services2006;
49.
Pettit  BWestern  B Mass imprisonment and the life course: race and class inequality in US incarceration. Am Sociol Rev 2004;69151- 169
50.
Fagan  MJDiaz  JAReinert  SESciamanna  CNFagan  DM Impact of interpretation method on clinic visit length. J Gen Intern Med 2003;18 (8) 634- 638
PubMed
51.
Willems  SDe Maesschalck  SDeveugele  MDerese  ADe Maeseneer  J Socioeconomic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2005;56 (2) 139- 146
PubMed
52.
Cooper-Patrick  LGallo  JJGonzales  JJ  et al.  Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282 (6) 583- 589
PubMed
53.
Wachtler  CBrorsson  ATroein  M Meeting and treating cultural difference in primary care: a qualitative interview study. Fam Pract 2006;23 (1) 111- 115
PubMed
54.
Davey Smith  GNeaton  JDWentworth  DStamler  RStamler  Jfor the Multiple Risk Factor Intervention Trial Research Group, Mortality differences between black and white men in the USA: contribution of income and other risk factors among men screened for the MRFIT. Lancet 1998;351 (9107) 934- 939
PubMed
55.
Lin  CCRogot  EJohnson  NJSorlie  PDArias  E A further study of life expectancy by socioeconomic factors in the National Longitudinal Mortality Study. Ethn Dis 2003;13 (2) 240- 247
PubMed
56.
Ng-Mak  DSDohrenwend  BPAbraido-Lanza  AFTurner  JB A further analysis of race differences in the National Longitudinal Mortality Study. Am J Public Health 1999;89 (11) 1748- 1751
PubMed
57.
Kessler  RC McGonagle  KAZhao  S  et al.  Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51 (1) 8- 19
PubMed
58.
Mauksch  LBTucker  SMKaton  WJ  et al.  Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract 2001;50 (1) 41- 47
PubMed
59.
Saha  SKomaromy  MKoepsell  TDBindman  AB Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med 1999;159 (9) 997- 1004
PubMed
60.
Gold  RMichael  YLWhitlock  EP  et al.  Race/ethnicity, socioeconomic status, and lifetime morbidity burden in the Women's Health Initiative: a cross-sectional analysis. J Womens Health (Larchmt) 2006;15 (10) 1161- 1173
PubMed
61.
Greenlund  KJKeenan  NLGiles  WH  et al.  Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001. Am Heart J 2004;147 (6) 1010- 1016
PubMed
62.
Greenlund  KJNeff  LJZheng  ZJ  et al.  Low public recognition of major stroke symptoms. Am J Prev Med 2003;25 (4) 315- 319
PubMed
63.
Neumann  MWirtz  MBollschweiler  E  et al.  Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modelling approach. Patient Educ Couns 2007;69 (1-3) 63- 75
PubMed
64.
Fiscella  KMeldrum  SFranks  P  et al.  Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care 2004;42 (11) 1049- 1055
PubMed
65.
Johnson  RLSaha  SArbelaez  JJBeach  MCCooper  LA Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004;19 (2) 101- 110
PubMed
66.
Hutton  CGunn  J Do longer consultations improve the management of psychological problems in general practice? a systematic literature review. BMC Health Serv Res 2007;771
PubMed10.1186/1472-6963-7-71
67.
Moore  CGProbst  JCTompkins  MCuffe  SMartin  AB The prevalence of violent disagreements in US families: effects of residence, race/ethnicity, and parental stress. Pediatrics 2007;119 ((suppl 1)) S68- S76
PubMed
68.
Fiscella  KFranks  P Does psychological distress contribute to racial and socioeconomic disparities in mortality? Soc Sci Med 1997;45 (12) 1805- 1809
PubMed
69.
Kleinman  ABenson  P Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Med 2006;3 (10) e294
PubMed
70.
Franks  PFiscella  KMeldrum  S Racial disparities in the content of primary care office visits. J Gen Intern Med 2005;20 (7) 599- 603
PubMed
71.
Wei  WFindley  PASambamoorthi  U Disability and receipt of clinical preventive services among women. Womens Health Issues 2006;16 (6) 286- 296
PubMed
72.
Maly  RCLeake  BSilliman  RA Health care disparities in older patients with breast carcinoma: informational support from physicians. Cancer 2003;97 (6) 1517- 1527
PubMed
73.
Brandon  DTIsaac  LALaveist  TA The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc 2005;97 (7) 951- 956
PubMed
74.
Murray  EPollack  LWhite  MLo  B Clinical decision-making: patients' preferences and experiences. Patient Educ Couns 2007;65 (2) 189- 196
PubMed
75.
Young  ASKlap  RSherbourne  CDWells  KB The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry 2001;58 (1) 55- 61
PubMed
76.
Mercer  SWFitzpatrick  BGourlay  GVojt  G McConnachie  AWatt  GCM More time for complex consultations in a high-deprivation practice is associated with increased patient enablement. Br J Gen Pract 2007;57 (545) 960- 966
PubMed
77.
Parchman  MLPugh  JARomero  RLBowers  KW Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med 2007;5 (3) 196- 201
PubMed
78.
Parchman  MLRomero  RLPugh  JA Encounters by patients with type 2 diabetes—complex and demanding: an observational study. Ann Fam Med 2006;4 (1) 40- 45
PubMed
79.
Burgess  DJFu  SSvan Ryn  M Why do providers contribute to disparities and what can be done about it? J Gen Intern Med 2004;19 (11) 1154- 1159
PubMed
80.
Rohrer  JEXu  KTBickley  L Duration of heart disease visits by elderly patients: productivity versus quality. Health Serv Manage Res 2002;15 (3) 141- 146
PubMed
81.
Dugdale  DCEpstein  RPantilat  SZ Time and the patient-physician relationship. J Gen Intern Med 1999;14 ((suppl 1)) S34- S40
PubMed
82.
Blumenthal  DCausino  NChang  YC  et al.  The duration of ambulatory visits to physicians. J Fam Pract 1999;48 (4) 264- 271
PubMed
83.
Berlowitz  DRAsh  ASGlickman  M  et al.  Developing a quality measure for clinical inertia in diabetes care. Health Serv Res 2005;40 (6, pt 1) 1836- 1853
PubMed
84.
O’Connor  PJ Overcome clinical inertia to control systolic blood pressure. Arch Intern Med 2003;163 (22) 2677- 2678
PubMed
85.
Grant  RWPirraglia  PAMeigs  JBSinger  DE Trends in complexity of diabetes care in the United States from 1991 to 2000. Arch Intern Med 2004;164 (10) 1134- 1139
PubMed
86.
Grant  RAdams  ASTrinacty  CM  et al.  Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care 2007;30 (4) 807- 812
PubMed
87.
Hicks  PCWestfall  JMVan Vorst  RF  et al.  Action or inaction? decision making in patients with diabetes and elevated blood pressure in primary care. Diabetes Care 2006;29 (12) 2580- 2585
PubMed
88.
Green  ARCarney  DRPallin  DJ  et al.  Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 2007;22 (9) 1231- 1238
PubMed
89.
Schulman  KABerlin  JAHarless  W  et al.  The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340 (8) 618- 626
PubMed
90.
McGuire  TGAyanian  JZFord  DEHenke  REMRost  KMZaslavsky  AM Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care. Health Serv Res 2008;43 (2) 531- 551
PubMed
91.
Groopman  J How Doctors Think.  New York, NY Houghton-Mifflin Co2007;
92.
Beach  MCRosner  MCooper  LADuggan  PSShatzer  J Can patient-centered attitudes reduce racial and ethnic disparities in care? Acad Med 2007;82 (2) 193- 198
PubMed
93.
Fiscella  KGoodwin  MAStange  KC Does patient educational level affect office visits to family physicians? J Natl Med Assoc 2002;94 (3) 157- 165
PubMed
94.
Wilson  IBKaplan  S Physician-patient communication in HIV disease: the importance of patient, physician, and visit characteristics. J Acquir Immune Defic Syndr 2000;25 (5) 417- 425
PubMed
95.
Schneider  JKaplan  SHGreenfield  SLi  WWilson  IB Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med 2004;19 (11) 1096- 1103
PubMed
96.
Eaton  CBGoodwin  MAStange  KC Direct observation of nutrition counseling in community family practice. Am J Prev Med 2002;23 (3) 174- 179
PubMed
97.
Tamblyn  RBerkson  LDauphinee  WD  et al.  Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med 1997;127 (6) 429- 438
PubMed
98.
Gotler  RSFlocke  SAGoodwin  MAZyzanski  SJMurray  THStange  KC Facilitating participatory decision-making: what happens in real-world community practice? Med Care 2000;38 (12) 1200- 1209
PubMed
99.
Kaplan  RCBhalodkar  NCBrown  EJ  JrWhite  JBrown  DL Race, ethnicity, and sociocultural characteristics predict noncompliance with lipid-lowering medications. Prev Med 2004;39 (6) 1249- 1255
PubMed
100.
Bosworth  HBDudley  TOlsen  MK  et al.  Racial differences in blood pressure control: potential explanatory factors. Am J Med 2006;119 (1) 70.e9- 70.e15http://www.amjmed.com/article/PIIS0002934305007515/fulltext
101.
Pappas  GHadden  WCKozak  LJFisher  GF Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups. Am J Public Health 1997;87 (5) 811- 816
PubMed
102.
Gupta  RSCarrion-Carire  VWeiss  KB The widening black/white gap in asthma hospitalizations and mortality. J Allergy Clin Immunol 2006;117 (2) 351- 358
PubMed
103.
Probst  JCGreenhouse  DLSelassie  AW Patient and physician satisfaction with an outpatient care visit. J Fam Pract 1997;45 (5) 418- 425
PubMed
104.
Singer  JDDavidson  SMGraham  SDavidson  HS Physician retention in community and migrant health centers: who stays and for how long? Med Care 1998;36 (8) 1198- 1213
PubMed
105.
Iglehart  JK Changing health insurance trends. N Engl J Med 2002;347 (12) 956- 962
PubMed
106.
Goodson  JD Unintended consequences of resource-based relative value scale reimbursement. JAMA 2007;298 (19) 2308- 2310
PubMed
107.
Chao  JGillanders  WGFlocke  SAGoodwin  MAKikano  GEStange  KC Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract 1998;47 (1) 28- 32
PubMed
108.
Miller  RHWest  CBrown  TMSim  IGanchoff  C The value of electronic health records in solo or small group practices. Health Aff (Millwood) 2005;24 (5) 1127- 1137
PubMed
109.
Menachemi  NMatthews  MCFord  EWBrooks  RG The influence of payer mix on electronic health record adoption by physicians. Health Care Manage Rev 2007;32 (2) 111- 118
PubMed
110.
Shields  AEShin  PLeu  MG  et al.  Adoption of health information technology in community health centers: results of a national survey. Health Aff (Millwood) 2007;26 (5) 1373- 1383
PubMed
111.
Clancy  DEHuang  POkonofua  EYeager  DMagruder  KM Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med 2007;22 (5) 620- 624
PubMed
112.
Kawasaki  LMuntner  PHyre  ADHampton  KDeSalvo  KN Willingness to attend group visits for hypertension treatment. Am J Manag Care 2007;13 (5) 257- 262
PubMed
113.
Sia  CTonniges  TFOsterhus  ETaba  S History of the medical home concept. Pediatrics 2004;113 (5) ((suppl)) 1473- 1478
PubMed
114.
Kellerman  RKirk  L Principles of the patient-centered medical home. Am Fam Physician 2007;76 (6) 774- 775
PubMed
115.
Goroll  AHBerenson  RASchoenbaum  SCGardner  LB Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med 2007;22 (3) 410- 415
PubMed
116.
Yano  EMSimon  BFLanto  ABRubenstein  LV The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality transformation. Am J Public Health 2007;97 (12) 2151- 2159
PubMed
117.
Audet  AMDavis  KSchoenbaum  SC Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med 2006;166 (7) 754- 759
PubMed
118.
Liu  CFFortney  JVivell  S  et al.  Time allocation and caseload capacity in telephone depression care management. Am J Manag Care 2007;13 (12) 652- 660
PubMed
119.
Denberg  TDRoss  SESteiner  JF Patient acceptance of a novel preventive care delivery system. Prev Med 2007;44 (6) 543- 546
PubMed
120.
Dietrich  AJTobin  JNCassells  A  et al.  Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial. Ann Intern Med 2006;144 (8) 563- 571
PubMed
121.
Pyper  CAmery  JWatson  MCrook  C Access to electronic health records in primary care: a survey of patients' views. Med Sci Monit 2004;10 (11) SR17- SR22
PubMed
122.
Gustafson  DH McTavish  FMStengle  W  et al.  Use and impact of e-health system by low-income women with breast cancer. J Health Commun 2005;10 ((suppl 1)) 195- 218
PubMed
123.
Kaplan  SH Patient reports of health status as predictors of physiologic health measures in chronic disease. J Chronic Dis 1987;40 ((suppl 1)) 27S- 40S
PubMed
124.
Gerber  BSBrodsky  IGLawless  KA  et al.  Implementation and evaluation of a low-literacy diabetes education computer multimedia application. Diabetes Care 2005;28 (7) 1574- 1580
PubMed
125.
Bodenheimer  TLaing  BY The teamlet model of primary care. Ann Fam Med 2007;5 (5) 457- 461
PubMed
126.
McKibben  LJStange  PVSneller  VPStrikas  RARodewald  LEfor the Advisory Committee on Immunization Practices, Use of standing orders programs to increase adult vaccination rates. MMWR Recomm Rep 2000;49 (RR-1) 15- 16
PubMed
127.
Paasche-Orlow  MKRiekert  KABilderback  A  et al.  Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med 2005;172 (8) 980- 986
PubMed
128.
Freeman  HP Patient navigation: a community based strategy to reduce cancer disparities. J Urban Health 2006;83 (2) 139- 141
PubMed
129.
Bradford  JBColeman  SCunningham  W HIV System Navigation: an emerging model to improve HIV care access. AIDS Patient Care STDS 2007;21 ((suppl 1)) S49- S58
PubMed
130.
Fiscella  KGeiger  HJ Health information technology and quality improvement for community health centers. Health Aff (Millwood) 2006;25 (2) 405- 412
PubMed
131.
Neuwirth  EBSchmittdiel  JATallman  KBellows  J Understanding panel management: comparative case studies of an emerging approach to population care. Permanente J 2008;11 (3) 11- 24
132.
Rudd  PMiller  NHKaufman  J  et al.  Nurse management for hypertension: a systems approach. Am J Hypertens 2004;17 (10) 921- 927
PubMed
133.
Fiscella  KShin  P The inverse care law: implications for healthcare of vulnerable populations. J Ambul Care Manage 2005;28 (4) 304- 312
PubMed
134.
Bodenheimer  T Coordinating care: a major (unreimbursed) task of primary care. Ann Intern Med 2007;147 (10) 730- 731
PubMed
135.
Institute of Medicine, Crossing the Quality Chasm: a New Health System for the 21st Century.  Washington, DC National Academy Press2001;
136.
Blustein  J Who is accountable for racial equity in health care? JAMA 2008;299 (7) 814- 816
PubMed
137.
Hasnain-Wynia  RBaker  DW Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res 2006;41 (4, pt 1) 1501- 1518
PubMed
138.
Fiscella  KFremont  AM Use of geocoding and surname analysis to estimate race and ethnicity. Health Serv Res 2006;41 (4, pt 1) 1482- 1500
PubMed
139.
Bajekal  MAlves  BJarman  BHurwitz  B Rationale for the new GP deprivation payment scheme in England: effects of moving from electoral ward to enumeration district underprivileged area scores. Br J Gen Pract 2001;51 (467) 451- 455
PubMed
140.
Verheij  RADe Bakker  DHReijneveld  SA GP income in relation to workload in deprived urban areas in the Netherlands: before and after the 1996 pay review. Eur J Public Health 2001;11 (3) 264- 266
PubMed
141.
Sundquist  KMalmstrom  MJohansson  SESundquist  J Care Need Index: a useful tool for the distribution of primary health care resources. J Epidemiol Community Health 2003;57 (5) 347- 352
PubMed
142.
Casalino  LPElster  A Will pay-for-performance and quality reporting affect health care disparities? [published correction appears in Health Aff (Milwood). 2007;26(6):1794]. Health Aff (Millwood) 2007;26 (3) w405- w414
PubMed
143.
Rosenthal  TCHorwitz  MESnyder  GO’Connor  J Medicaid primary care services in New York state: partial capitation vs full capitation. J Fam Pract 1996;42 (4) 362- 368
PubMed
144.
Weissman  JSBetancourt  JCampbell  EG  et al.  Resident physicians' preparedness to provide cross-cultural care. JAMA 2005;294 (9) 1058- 1067
PubMed
145.
Smith  WRBetancourt  JRWynia  MK  et al.  Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med 2007;147 (9) 654- 665
PubMed
146.
Maguire  PFaulkner  ABooth  KElliott  CHillier  V Helping cancer patients disclose their concerns. Eur J Cancer 1996;32A (1) 78- 81
PubMed
147.
Heritage  JRobinson  JDElliott  MNBeckett  MWilkes  M Reducing patients unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007;22 (10) 1429- 1433
PubMed
148.
Mauksch  LBHillenburg  LRobins  L The establishing focus protocol: training for collaborative agenda setting and time management in the medical review. Fam Syst Health 2001;19147- 157
149.
Lewin  SASkea  ZCEntwistle  VDick  JZwarenstein  M Interventions for Providers to Promote a Patient-Centered Approach in Clinical Consultations.  Oxford, England Update Software2001;
150.
Smith  RCMettler  JAStoffelmayr  BE  et al.  Improving residents' confidence in using psychosocial skills. J Gen Intern Med 1995;10 (6) 315- 320
PubMed
151.
Brown  RFButow  PNDunn  SMTattersall  MH Promoting patient participation and shortening cancer consultations: a randomised trial. Br J Cancer 2001;85 (9) 1273- 1279
PubMed
152.
Kripalani  SBussey-Jones  JKatz  MGGenao  I A prescription for cultural competence in medical education. J Gen Intern Med 2006;21 (10) 1116- 1120
PubMed
153.
Betancourt  JR Cultural competence: marginal or mainstream movement? N Engl J Med 2004;351 (10) 953- 955
PubMed
154.
Murray  MBodenheimer  TRittenhouse  DGrumbach  K Improving timely access to primary care: case studies of the advanced access model. JAMA 2003;289 (8) 1042- 1046
PubMed
155.
O’Connor  MEMatthews  BSGao  D Effect of open access scheduling on missed appointments, immunizations, and continuity of care for infant well-child care visits. Arch Pediatr Adolesc Med 2006;160 (9) 889- 893
PubMed
156.
Ludman  EJSimon  GETutty  SVon Korff  M A randomized trial of telephone psychotherapy and pharmacotherapy for depression: continuation and durability of effects. J Consult Clin Psychol 2007;75 (2) 257- 266
PubMed
157.
An  LCZhu  SHNelson  DB  et al.  Benefits of telephone care over primary care for smoking cessation: a randomized trial. Arch Intern Med 2006;166 (5) 536- 542
PubMed
158.
O’Malley  AJLandon  BEGuadagnoli  E Analyzing multiple informant data from an evaluation of the health disparities collaboratives. Health Serv Res 2007;42 (1 pt 1) 146- 164
PubMed
159.
Szilagyi  PGSchaffer  SShone  L  et al.  Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics 2002;110 (5) e58
PubMed10.1542/peds.110.5.e58
160.
Landon  BEHicks  LSO’Malley  AJ  et al.  Improving the management of chronic disease at community health centers. N Engl J Med 2007;356 (9) 921- 934
PubMed
161.
Batalden  PBMohr  JJNelson  EC  et al.  Continually improving the health and value of health care for a population of patients: the panel management process. Qual Manag Health Care 1997;5 (3) 41- 51
PubMed
162.
Hypertension Detection and Follow-up Program Cooperative Group, Five-year findings of the hypertension detection and follow-up program, II: mortality by race-sex and age. JAMA 1979;242 (23) 2572- 2577
PubMed
163.
Multiple Risk Factor Intervention Trial Research Group, Mortality rates after 10.5 years for participants in the Multiple Risk Factor Intervention Trial: findings related to a priori hypotheses of the trial. JAMA 1990;263 (13) 1795- 1801
PubMed
164.
Goldman  DPSmith  JP Can patient self-management help explain the SES health gradient? Proc Natl Acad Sci U S A 2002;99 (16) 10929- 10934
PubMed
165.
Bodenheimer  TLorig  KHolman  HGrumbach  K Patient self-management of chronic disease in primary care. JAMA 2002;288 (19) 2469- 2475
PubMed
166.
O’Connor  AMBennett  CStacey  D  et al.  Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? a systematic review and meta-analysis. Med Decis Making 2007;27 (5) 554- 574
PubMed
167.
Gilbody  SBower  PFletcher  JRichards  DSutton  AJ Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006;166 (21) 2314- 2321
PubMed
168.
Karliner  LSJacobs  EAChen  AHMutha  S Do professional interpreters improve clinical care for patients with limited English proficiency? a systematic review of the literature. Health Serv Res 2007;42 (2) 727- 754
PubMed
169.
Jandorf  LGutierrez  YLopez  JChristie  JItzkowitz  SH Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. J Urban Health 2005;82 (2) 216- 224
PubMed
170.
Ell  KVourlekis  BLee  PJXie  B Patient navigation and case management following an abnormal mammogram: a randomized clinical trial. Prev Med 2007;44 (1) 26- 33
PubMed
171.
Gardner  LIMetsch  LRAnderson-Mahoney  P  et al.  Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS 2005;19 (4) 423- 431
PubMed
172.
Nagykaldi  ZMold  JWAspy  CB Practice facilitators: a review of the literature. Fam Med 2005;37 (8) 581- 588
PubMed
173.
Greenfield  SKaplan  SWare  JE  Jr Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med 1985;102 (4) 520- 528
PubMed
174.
Brown  RButow  PNBoyer  MJTattersall  MH Promoting patient participation in the cancer consultation: evaluation of a prompt sheet and coaching in question-asking. Br J Cancer 1999;80 (1-2) 242- 248
PubMed
175.
Williams  GC McGregor  HAZeldman  AFreedman  ZRDeci  EL Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychol 2004;23 (1) 58- 66
PubMed
176.
Oliver  JWKravitz  RLKaplan  SHMeyers  FJ Individualized patient education and coaching to improve pain control among cancer outpatients. J Clin Oncol 2001;19 (8) 2206- 2212
PubMed
177.
Greenfield  SKaplan  SHWare  JE  JrYano  EMFrank  HJ Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3 (5) 448- 457
PubMed
178.
Roter  DL Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction, and compliance. Health Educ Monogr 1977;5 (4) 281- 315
PubMed
179.
Crabtree  BFMiller  WLTallia  AF  et al.  Delivery of clinical preventive services in family medicine offices. Ann Fam Med 2005;3 (5) 430- 435
PubMed
180.
Institute of Medicine, Envisioning the National Health Care Quality Report.  Washington, DC National Academy Press2001;
Special Article
September 22, 2008

So Much to Do, So Little TimeCare for the Socially Disadvantaged and the 15-Minute Visit

Author Affiliations

Author Affiliations: Departments of Family Medicine (Drs Fiscella and Epstein), Community and Preventive Medicine (Dr Fiscella), and Psychiatry (Dr Epstein), and Division of Oncology, James P. Wilmot Cancer Center (Drs Fiscella and Epstein), University of Rochester School of Medicine & Dentistry, Rochester, New York.

Arch Intern Med. 2008;168(17):1843-1852. doi:10.1001/archinte.168.17.1843
Abstract

There is so much to do in primary care, and so little time to do it. During 15-minute visits, physicians are expected to form partnerships with patients and their families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision making that respects patients' needs and preferences. This is a challenging task during straightforward visits, and it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.

Mrs S is a 52-year-old housekeeper with poorly controlled diabetes mellitus, hypertension, and obesity who missed her last 2 visits because of job conflicts. She has not reached her annual insurance deductible and pays for the visit out of pocket. She speaks limited English, and the receptionist translates. Dr M explores her complaints of fatigue, daily headaches, back pain, and conflict with her husband after his job loss. Dr M conducts a thorough medical history and physical examination and concludes that Mrs S's poorly controlled diabetes mellitus, night shifts, work, and depression are contributing to her symptoms. He recommends mental health counseling, but Mrs S declines. Dr M recommends an antidepressant and adds 2 new medications for diabetes and blood pressure and reviews their purposes and adverse effects. Mrs S politely acquiesces, knowing she cannot afford them and doubting their benefit. The receptionist interrupts Dr M to tell him he is behind, and he quickly concludes the visit. Mrs S leaves the office still worried about her health and the costs of care. Because the visit takes 30 minutes, her office fee does not fully cover visit costs. Dr M despairingly notes that none of Mrs S's preventive or chronic disease quality measures meet local standards. He considers discharging her from his practice for nonadherence to avoid being penalized under pay-for-performance.

As illustrated, constraining care to 15-minute visits for socially disadvantaged patients virtually ensures the perpetuation of health care disparities. Socially disadvantaged patients, often referred to as vulnerable or underserved, are at higher risk for multiple risk factors because of shared social characteristics.1 They include members of racial and ethnic minority groups and persons with low literacy and low socioeconomic status.2 These groups, although distinct, overlap considerably, resulting in concentration of risk for patients.3

In this article, we illustrate how the 15-minute office visit discriminates against socially disadvantaged patients and propose fundamental reform in primary care structure and payment to address the problem.

SO LITTLE TIME

The average office visit in the United States lasts for about 16 minutes,4 not enough time to effectively address multiple complex problems.5 Typically, 5 minutes are spent on one problem and a minute or 2 on the remainder.6 Providing all recommended preventive and chronic disease care takes far more time than is available during 2 adult primary care visits per year.7 To provide guideline-concordant care, a physician caring for a usual panel of patients would need to spend 35 hours on preventive health care during a typical week,8 another 50 hours on patients' chronic care needs,9 and unknown hours for acute care, in addition to the 8 hours primary care physicians currently spend on patient care outside of office visits.10 These time constraints severely limit informed decision making5 and confirmation of patient understanding,11 and commonly result in omission of discussion of adverse medication effects and costs.12,13 For socially disadvantaged patients, who more commonly have multiple, complex, biomedical, and psychosocial problems, care is worse.12,13

SO MUCH TO DO

Caring for socially disadvantaged patients poses unique challenges, requiring more time and greater team work (Table 1).14 Communication across differences in language, culture, and health literacy takes time.26,5053 Socially disadvantaged patients experience worse physical5456 and mental health,22,57,58 including more impairments in vision, hearing, and cognition that slow communication.15

Review of the main parts of the office visit illustrates the key challenges of caring for socially disadvantaged patients during 15-minute visits.28 Initiating the visit involves establishing rapport and identifying the reasons for the visit. Achieving rapport across races, ethnicities, and educational levels can be challenging.29,59 Eliciting all the reasons for the visit and negotiating an agenda may take longer because socially disadvantaged patients have more concerns,14,16 symptoms,15 and illnesses.60 Patients with low health literacy may not recognize key symptoms as readily.61,62 Time pressures may undermine physician empathy63 and patient trust,64 particularly among marginalized patients.65

Gathering information about the illness, including key symptoms and psychosocial context, is more time consuming because socially disadvantaged patients may have more symptoms, more complex illnesses,66 and greater psychosocial stress.67,68 Exploration of patients' perspectives is critical to establishing a partnership and understanding patients' beliefs, but is also more time consuming across sociocultural distance.69

Physical examination may also take longer owing to greater illness burden and disabilities that slow the process.15 Preventive care involving disrobing (eg, Pap smears or breast and rectal examinations) is less likely to happen.70,71

Discussion of diagnosis and treatment involves exchange of illness-related information, confirmation of patient understanding,35 complex decision making, and promotion of behavior change.5,14 Each of these tasks may take longer because of differences in language,26,27 health literacy,24,25 health beliefs, culture,72 and levels of trust.65,73 Participatory decision making may seem unfamiliar to historically marginalized patients.74 In addition, primary care physicians frequently provide time-consuming mental health counseling to socially disadvantaged patients who do not have access to or are suspicious of psychiatrists or psychologists.75 Addressing barriers to specialty referral and adherence takes time.38,39

Closure of the visit—summarizing the diagnosis, treatment plan, and follow-up instructions—takes longer when communication barriers are present. Lengthening visits can help; longer visits are associated with increased empowerment among socially disadvantaged patients.76

EFFECT ON CARE

There has been little systematic study of the effects of 15-minute visits on care for socially disadvantaged patients. However, time-pressured visits contribute to competing demands, clinical inertia, unconscious physician bias, and physician-centered communication.7779 Each of these likely contributes to disparities in care. Shorter visits are associated with diminished quality,80 and discussions of prevention and psychosocial issues suffer.81 Yet, socially disadvantaged patients receive shorter, not longer, visits30,82 and fewer visits per year.7

Clinical inertia refers to the failure to implement appropriate clinical action in the context of inadequate chronic disease control.83,84 Clinical inertia is exacerbated by multiple patient demands and time pressures85 and by physician suspicion of poor adherence.86,87 It takes less time to “wait and watch” than to implement a change in treatment plan.

Unconscious physician stereotypes affect care.31,88,89 Unconscious bias often emerges during periods of stress and time pressure.79 Physicians, challenged to address the complex needs of patients during a few minutes, more readily simplify these mental tasks by resorting to stereotypical thinking. Busy physicians may attend to data that conform to preconceived notions, such as nonadherence,31 on the basis of group membership and ignore disconfirming data. In addition, communication with socially disadvantaged patients may result in misinterpretations, even when both parties speak the same language.90 These misinterpretations are likely to result in lack of agreement about the illness, its treatment, and the patient's role in care.69 When decision making is rushed, clinical judgment relies increasingly on heuristics, cognitive short-cuts, that often fail to account for individual needs.91

Patient-centered communication mitigates some of the effects of social disadvantage on care.92 However, patient-centered behaviors, such as asking patients about their own beliefs, engaging patients in collaborative decision making, identifying adherence barriers, confirming patients' understanding, and using interpreters, take more time.26 Perhaps owing to time pressure, physicians engage in less, not more, patient-centered communication with socially disadvantaged patients.93

DISPARITIES IN CARE

The potential consequences of 15-minute visits on socially disadvantaged patients include disparities in patient understanding and satisfaction, low adherence, and suboptimal preventive and chronic disease care.94100 Socially disadvantaged patients experience more adverse outcomes (eg, preventable hospitalizations and deaths),101,102 and physicians caring for them experience higher burnout.103,104

These disparities may be avoidable. Findings from randomized trials show that team-based, intensive interventions improve health care quality among socially disadvantaged patients and reduce health care disparities across a range of conditions.41 Multifaceted, nurse-led programs and culturally sensitive care may also be effective.42 However, most of these interventions extend beyond the scope of 15-minute physician-directed office visits. Findings, from externally funded research projects, require specific translation into clinical practice, including implementation of new care models supported by new payment systems.

CURRENT OPTIONS

There are a handful of options within current health care systems (Table 2). The most obvious are to schedule patients more frequently or for longer visits. However, health plans have increasingly shifted costs onto patients through higher copayments and reduced coverage,105 disproportionately affecting socially disadvantaged patients' ability to see physicians more frequently. In addition, many topics are best addressed in a single visit rather than spread out for a long period.106 Billing coding is based primarily on chart documentation rather than on patients' needs, including language, health literacy, cultural, or adherence barriers. Longer visits are undercoded.107

Time for paperwork, such as certification of disability or documentation of eligibility for social services, follow-up on abnormal test results, and out-of-visit medication management, is not reimbursed.10 Electronic medical records can improve documentation and increase reimbursement,108 but fewer practices serving socially disadvantaged patients have implemented them.109,110

Group visits offer a potentially viable alternative for some patients.111 These allow extended time for teaching, discussion, and sharing of experience among patients. However, most health plans do not pay for group visits, and some patients may feel uncomfortable talking in a group about their health or psychosocial concerns.112

Ultimately, improving care for socially disadvantaged patients requires more than just longer visits. It requires scrapping a care model predicated exclusively on physician-directed, visit-based care and replacing it with a new model, such as the Patient-Centered Medical Home (PCMH).

PATIENT-CENTERED MEDICAL HOME

The PCMH arose from the need for a single physician or practice to assume responsibility for coordinating the care for children with special health care needs.113 The purpose of the PCMH is to provide access to primary health care teams built around patients' needs. It depends on appropriate team training and patient activation and is explicitly designed to enhance patient choice, quality, safety, and efficiency. The 7 core principles of the PCMH have been endorsed by the major primary care physician organizations, and there is growing support for it among payers and members of Congress.114 The first 6 principles represent historic primary care ideals: having a personal primary care physician, team-based care directed by a physician, whole person orientation, coordination of all facets of care, focus on quality and safety, and enhanced access to care.114 The seventh principle, payment reform, provides means for implementing these principles.114

The PCMH represents an idealized model of care for all patients,115 and many practices and organizations, including the Veterans Affairs Administration Health System,116 have already begun to implement many of its features.117 It offers particular promise for improving care for socially disadvantaged patients, as illustrated by the following description of an ideal practice.

A radically restructured primary care team might consist of 1 physician, 1 nurse practitioner (or physician assistant), a patient panel manager, and several registered nurses and medical assistants assigned a defined panel of patients. Tasks are distributed based on capability rather than traditional roles. Exploration of new symptoms and patient concerns likely occurs in-person with the physician, whereas other issues may be addressed through individual or group meetings with nurses and other health care professionals.118 Professional language interpreters are universally available and funded. Phone visits,119,120 and secure e-mail when feasible, are used to address some routine concerns and to monitor progress. A secure Web server facilitates patients' direct access to their medical records, including the ability to update health information,121 as digital technology diffuses to socially disadvantaged populations.122 More important, a member of the team, perhaps a nurse, is always available to supplement electronic communications, for example, when patients need to understand test results that are made available online. Providing patients with key information about their health along with the means to understand this information represents a critical step toward patient empowerment.123

These innovations reflect a radical redefinition of the roles of the health care team and patient. Patients are trained to provide critical health and health care updates through various modalities. Although many patients communicate electronically with the health care team from home, user-friendly computer kiosks are available in the office for patients who lack reliable Web access; these are also used for in-office demonstrations and training.124

Many traditional physician responsibilities are distributed among the health care team to ensure that the physicians' time is used wisely, for duties such as the assessment of complex problems, discussion of a new diagnosis, meeting with patients and their families, or deliberation about treatment options. A medical assistant updates medical data, reviews preventive care, and helps patients identify concerns before the physician visit.125 Routine preventive care is provided by the nurse through standing orders, allowing the physician to address more complex or unresolved concerns in greater depth.125,126 In the vignette, a certified interpreter would translate for Mrs S, and the team would quickly identify and address her suboptimal health care quality.

Following physician-patient encounters, medical assistants or nurses routinely follow-up by phone or in-person to elicit the patient's understanding of the diagnoses and treatment plans, correct misunderstandings, address barriers to care,127 and link patients to community resources such as patient navigation.128,129 In the case of Mrs S, the nurse, or perhaps a team pharmacist, would identify less expensive blood pressure medications and engage the patient with self-management groups or even community-based job training for her husband. Ideally, Mrs S would leave the visit feeling more empowered in self-management.

All abnormal laboratory test results as well as preventive and chronic disease care are tracked using electronic registries.130 Most important, all members of the care team are expected and funded to meet regularly for patient panel management, eg, to review reports, recall patients, and implement changes in treatment.131 In the case of Mrs S, the nurse would identify her nonadherence based on review of her electronic medication refill history, and the team would develop a plan for addressing it.132 Use of a team, particularly a culturally diverse one, to assess these complex issues outside of time-pressured 15-minute visits, minimizes implicit bias and facilitates deliberation of treatment options using decision-support tools and evidence-based guidelines.131

NEW PAYMENT MODELS

This transformation of primary care requires radical payment reform. Such reform must account for the greater health care needs of socially disadvantaged patients.133 Current fee-for-service payment, predicated on performance of a discrete procedure performed on the patient at a single point in time, is a poor fit for primary care.115,134 Exclusive fee-for-service payment is particularly detrimental for patients with complex needs who require not only longer visits but also care outside of visits or care by ancillary staff. There is emerging consensus that such payments represent a major obstacle to primary care redesign and quality improvement.135 It is less widely recognized that current payment models undermine a core dimension of health care quality—equity.

The PCMH principles suggest 4 potential sources of proposed revenue114: (1) current visit-based reimbursement, potentially expanded to include non–face-to-face patient visits; (2) payment for nonvisit care, such as care coordination, health information technology, remote clinical monitoring, and population-based management; (3) pay-for-performance, such as bonuses for improved quality; and (4) shared savings from potential reductions in health care costs.

Implementation of the PCMH for socially disadvantaged patients requires payments that recognize the actual costs of high quality care for these patients.115,133 Currently, such care is underresourced and often lower in quality.40,136

Ideally, “payments should recognize case-mix differences in the patient population being treated within the practice.”114(p775) For example, visit-based reimbursement might be based on the time spent with the patient rather than current complex coding formulas. Monthly payments per enrolled patient should be increased according to the social disadvantage of the patient population.115 This could be based on individual patient sociodemographic data, requiring notation of patients' race, ethnicity, educational level, and primary language.137 Alternatively, proxy information derived from patient addresses geocoded to US Census data can be used.138 Several European countries use the latter approach to increase payments to practices serving socially disadvantaged patients.138141

Pay-for-performance could be made more equitable by comparing practices serving socially disadvantaged patients with each other and by rewarding improvements in performance, rather than just achievement of benchmarks. The surest way to improve equity in pay-for-performance and to avoid the unintended consequence of worsening disparities142 is to allocate resources to practices based on patient need. Last, even basic PCMHs reduce Medicaid costs.143 These cost savings should be shared with practices.

PHYSICIAN AND STAFF TRAINING

A new model of primary health care should free physicians to attend to the most critical patient needs, for which they are ideally trained, and free them from tasks that could be performed by other members of the team. Although structural and financial changes are necessary, they are not sufficient. The health care workforce must be adequately trained to elicit and provide information effectively and empower, activate, inform, and involve patients in their care.

Physicians need training in new skills,144,145 and, most important, new roles. Physician training may partially mitigate time pressure. Training in specific communication skills can improve elicitation of patients' concerns146,147 and organization of the visit,148 while also reducing visit length. Physician training improves patient-centered communication skills,149 empathy,150 and responsiveness to patients' questions.151 Specific training in cultural competence may improve communication with socially disadvantaged populations.152

New communication skills are necessary to facilitate team-based care and to optimize care for socially disadvantaged patients.153 These skills include team leadership and management; panel management; communication within health care teams; giving feedback to coworkers; electronic communication with colleagues and with patients; longitudinal care; collaborating with off-site care managers, patient navigators, interpreters, and families; and customizing risk information for low-literacy patients (Table 3). In addition, training and guidance by an external practice enhancement assistant may be needed to facilitate practice change.172

It is especially important to train physicians and other team members to recognize, promote, and support patient participation in care, particularly among those who are socially disadvantaged. These changes represent a cultural shift from the traditional hierarchies within patient-physician relationships and among members of the health care team. These changes will not come easily and are best initiated early in training.

PATIENT TRAINING AND RESOURCES

Socially disadvantaged patients can be empowered to take more active roles in their care.123,173 Individualized patient coaching, use of prompt lists containing commonly asked questions, and computer programs increase patient participation during visits (eg, question asking)174 and potentially improve adherence,175 symptom control,176 and chronic disease outcomes.123,177 Decision aids assist with informed decision making; they should be expanded to provide information while also encouraging patients to participate in discussions with their physicians about their care. Furthermore, although increased patient participation may improve care, it may also create tension in the patient-physician relationship178 unless physicians specifically endorse patient involvement.151 Although untested, patient activation combined with physician training in organizing the visit has the potential to improve care while also limiting visit time.148 Patient training can be effectively integrated, at multiple points in care by different team members, using various communication modalities. Improvements in technology will facilitate tailoring of training to the cultural, language, and health literacy needs of the patient.

PHYSICIAN LEADERSHIP

Practice redesign requires strong physician leadership to implement new systems of care, reallocate existing tasks, and actively support new models of patient participation in care. Such reforms represent a fundamental cultural shift in the practice of primary care and cannot succeed without strong physician commitment to reform. Changes in payment models, implementation of health information technology, and training in collaborative care models represent necessary, but not sufficient, conditions for new care models. Success will ultimately depend on the willingness of physicians to champion practice redesign and quality, delegate traditional tasks to team members, and create genuine partnerships with historically disadvantaged patients.179

CONCLUSIONS

The mismatch between patients' needs and the time and resources available to address those needs is greatest for socially disadvantaged patients, thereby exacerbating disparities in access to, process of, and outcomes of health care. A couple of 15-minute visits per year is too little time to provide patient-centered, evidence-based, safe, high quality care for the average patient and particularly for socially disadvantaged patients. Therefore, elimination of health care disparities requires reform of primary care delivery so that care extends beyond 15-minute face-to-face visits. Work that has been the exclusive domain of physicians should include multidisciplinary teams caring for patients through multiple modalities. Such radical reform requires major changes in the structure of payment for primary care. In particular, health care resources must be allocated according to the health care needs of patients so that practices serving socially disadvantaged patients receive more, not fewer, resources. Only in this way can primary care “ensure that decisions respect the patients' wants, needs, and preferences and that patients have the education and support to make decisions and participate in care.”180(p7) However critical, payment reform alone is not enough and transformation of primary care will not come easily. Physician leadership and commitment, change in practice culture, new training programs for health care professionals and patients, and focused research are required to optimize care models for socially disadvantaged patients.

Correspondence: Kevin Fiscella, MD, MPH, Department of Family Medicine, University of Rochester School of Medicine & Dentistry, 1381 South Ave, Rochester, NY 14620 (Kevin_Fiscella@urmc.rochester.edu).

Accepted for Publication: March 30, 2008.

Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Fiscella and Epstein. Analysis and interpretation of data: Fiscella. Drafting of the manuscript: Fiscella. Critical revision of the manuscript for important intellectual content: Fiscella and Epstein. Obtained funding: Fiscella. Administrative, technical, or material support: Epstein.

Financial Disclosure: None reported.

Funding/Support: This study was supported in part by grant U01CA116924-01 from the National Cancer Institute and grant R01 HL081066-01A2 from the National Heart, Lung, and Blood Institute.

Role of the Sponsors: The sponsors had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript.

Disclaimer: The views expressed in this paper represent solely those of the authors and in no way reflect endorsement by either funder.

Additional Contributions: Thomas Bodenheimer, MD, Rick Botelho, MD, Tom Campbell, MD, Jennifer Carroll, MD, Elizabeth Finigan, MD, Clint Koenig, MD, Gordon Moore, MD, and the anonymous reviewers provided helpful comments regarding earlier versions of this article.

References
1.
Frohlich  KLPotvin  L Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health 2008;98 (2) 216- 221
PubMed
2.
Aday  LA At Risk in America: the Health and Health Care Needs of Vulnerable Populations in the United States.  San Francisco, CA Jossey-Bass Publishers1993;
3.
Shi  LStevens  GD Vulnerable Populations in the United States.  San Francisco, CA Jossey-Bass2005;
4.
Mechanic  D McAlpine  DDRosenthal  M Are patients' office visits with physicians getting shorter? N Engl J Med 2001;344 (3) 198- 204
PubMed
5.
Braddock  CH  IIIEdwards  KAHasenberg  NMLaidley  TLLevinson  W Informed decision making in outpatient practice: time to get back to basics. JAMA 1999;282 (24) 2313- 2320
PubMed
6.
Tai-Seale  M McGuire  TGZhang  W Time allocation in primary care office visits. Health Serv Res 2007;42 (5) 1871- 1894
PubMed
7.
Burt  CW McCaig  LFRechtsteiner  EA Ambulatory medical care utilization estimates for 2005. Adv Data 2007;388 (388) 1- 16
PubMed
8.
Yarnall  KSPollak  KIØstbye  TKrause  KMMichener  JL Primary care: is there enough time for prevention? Am J Public Health 2003;93 (4) 635- 641
PubMed
9.
Østbye  TYarnall  KSKrause  KMPollak  KIGradison  MMichener  JL Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3 (3) 209- 214
PubMed
10.
Farber  JSiu  ABloom  P How much time do physicians spend providing care outside of office visits? Ann Intern Med 2007;147 (10) 693- 698
PubMed
11.
Braddock  CH  IIIFihn  SDLevinson  WJonsen  ARPearlman  RA How doctors and patients discuss routine clinical decisions: informed decision making in the outpatient setting. J Gen Intern Med 1997;12 (6) 339- 345
PubMed
12.
Tarn  DMHeritage  JPaterniti  DAHays  RDKravitz  RLWenger  NS Physician communication when prescribing new medications. Arch Intern Med 2006;166 (17) 1855- 1862
PubMed
13.
Tarn  DMPaterniti  DAHeritage  JHays  RDKravitz  RLWenger  NS Physician communication about the cost and acquisition of newly prescribed medications. Am J Manag Care 2006;12 (11) 657- 664
PubMed
14.
Blankfield  RPGoodwin  MJaen  CRStange  KC Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices. J Urban Health 2002;79 (2) 173- 185
PubMed
15.
Bierman  ASLawrence  WFHaffer  SCClancy  CM Functional health outcomes as a measure of health care quality for Medicare beneficiaries. Health Serv Res 2001;36 (6, pt 2) 90- 109
PubMed
16.
Mercer  SWWatt  GC The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med 2007;5 (6) 503- 510
PubMed
17.
Schoenborn  CAVickerie  JLPowell-Griner  E Health characteristics of adults 55 years of age and over: United States, 2000-2003. Adv Data 2006;370 (370) 1- 31
PubMed
18.
Zahran  HSKobau  RMoriarty  DGZack  MMHolt  JDonehoo  R Health-related quality of life surveillance–United States, 1993-2002. MMWR Surveill Summ 2005;54 (4) 1- 35
PubMed
19.
Schnittker  J Social distance in the clinical encounter: interactional and sociodemographic foundations for mistrust in physicians. Soc Psychol Q 2004;67 (3) 217- 235
20.
Lantz  PMLynch  JWHouse  JS  et al.  Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors. Soc Sci Med 2001;53 (1) 29- 40
PubMed
21.
Centers for Disease Control and Prevention, Prevalence of fruit and vegetable consumption and physical activity by race/ethnicity: United States, 2005. MMWR Morb Mortal Wkly Rep 2007;56 (13) 301- 304
PubMed
22.
Adelmann  PK Mental and substance use disorders among Medicaid recipients: prevalence estimates from two national surveys. Adm Policy Ment Health 2003;31 (2) 111- 129
PubMed
23.
Dougherty  RHfor the American College of Mental Health Administration, Reducing disparity in behavioral health services: a report from the American College of Mental Health Administration. Adm Policy Ment Health 2004;31 (3) 253- 263
PubMed
24.
Baker  DWWolf  MSFeinglass  JThompson  JAGazmararian  JAHuang  J Health literacy and mortality among elderly persons. Arch Intern Med 2007;167 (14) 1503- 1509
PubMed
25.
Paasche-Orlow  MKParker  RMGazmararian  JANielsen-Bohlman  LTRudd  RR The prevalence of limited health literacy. J Gen Intern Med 2005;20 (2) 175- 184
PubMed
26.
Karliner  LSPerez-Stable  EJGildengorin  G The language divide: the importance of training in the use of interpreters for outpatient practice. J Gen Intern Med 2004;19 (2) 175- 183
PubMed
27.
Weech-Maldonado  RMorales  LSElliott  MSpritzer  KMarshall  GHays  RD Race/ethnicity, language, and patients' assessments of care in Medicaid managed care. Health Serv Res 2003;38 (3) 789- 808
PubMed
28.
Kurtz  SSilverman  JBenson  JDraper  J Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides. Acad Med 2003;78 (8) 802- 809
PubMed
29.
Lott  B Cognitive and behavioral distancing from the poor. Am Psychol 2002;57 (2) 100- 110
PubMed
30.
Cooper  LARoter  DLJohnson  RLFord  DESteinwachs  DMPowe  NR Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003;139 (11) 907- 915
PubMed
31.
van Ryn  MBurke  J The effect of patient race and socioeconomic status on physicians' perceptions of patients. Soc Sci Med 2000;50 (6) 813- 828
PubMed
32.
Carrillo  JEGreen  ARBetancourt  JR Cross-cultural primary care: a patient-based approach. Ann Intern Med 1999;130 (10) 829- 834
PubMed
33.
Fiscella  KFranks  PClancy  CM Skepticism toward medical care and health care utilization. Med Care 1998;36 (2) 180- 189
PubMed
34.
Rosen  ABTsai  JSDowns  SM Variations in risk attitude across race, gender, and education. Med Decis Making 2003;23 (6) 511- 517
PubMed
35.
Schillinger  DPiette  JGrumbach  K  et al.  Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163 (1) 83- 90
PubMed
36.
Jacobs  EChen  AHKarliner  LSAgger-Gupta  NMutha  S The need for more research on language barriers in health care: a proposed research agenda. Milbank Q 2006;84 (1) 111- 133
PubMed
37.
Miller  MJDegenholtz  HBGazmararian  JALin  CJRicci  EMSereika  SM Identifying elderly at greatest risk of inadequate health literacy: a predictive model for population-health decision makers. Res Social Adm Pharm 2007;3 (1) 70- 85
PubMed
38.
Betancourt  JRCarrillo  JEGreen  AR Hypertension in multicultural and minority populations: linking communication to compliance. Curr Hypertens Rep 1999;1 (6) 482- 488
PubMed
39.
Briesacher  BAGurwitz  JHSoumerai  SB Patients at risk for cost-related medication nonadherence: a review of the literature. J Gen Intern Med 2007;22 (6) 864- 871
PubMed
40.
Bach  PBPham  HHSchrag  DTate  RCHargraves  JL Primary care physicians who treat blacks and whites. N Engl J Med 2004;351 (6) 575- 584
PubMed
41.
Fiscella  K Eliminating disparities in health care through quality improvement. Williams  REliminating Healthcare Disparities in America Beyond the IOM Report. Totowa, NJ Humana Press2007;
42.
Chin  MHWalters  AECook  SCHuang  ES Interventions to reduce racial and ethnic disparities in health care. Med Care Res Rev 2007;64 (5) ((suppl)) 7S- 28S
PubMed
43.
Trivedi  ANZaslavsky  AMSchneider  ECAyanian  JZ Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353 (7) 692- 700
PubMed
44.
Hertz  RPUnger  ANCornell  JASaunders  E Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med 2005;165 (18) 2098- 2104
PubMed
45.
Kaplan  RCBhalodkar  NCBrown  DLWhite  JBrown  EJ  Jr Differences by age and race/ethnicity in knowledge about hypercholesterolemia. Cardiol Rev 2006;14 (1) 1- 6
PubMed
46.
Pancioli  AMBroderick  JKothari  R  et al.  Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998;279 (16) 1288- 1292
PubMed
47.
Ribisl  KMWinkleby  MAFortmann  SPFlora  JA The interplay of socioeconomic status and ethnicity on Hispanic and white men's cardiovascular disease risk and health communication patterns. Health Educ Res 1998;13 (3) 407- 417
PubMed
48.
Administration for Children and Families, US Department of Health and Human Services, Temporary Assistance for Needy Families (TANF): Seventh Annual Report to Congress.  Washington, DC US Dept of Health and Human Services2006;
49.
Pettit  BWestern  B Mass imprisonment and the life course: race and class inequality in US incarceration. Am Sociol Rev 2004;69151- 169
50.
Fagan  MJDiaz  JAReinert  SESciamanna  CNFagan  DM Impact of interpretation method on clinic visit length. J Gen Intern Med 2003;18 (8) 634- 638
PubMed
51.
Willems  SDe Maesschalck  SDeveugele  MDerese  ADe Maeseneer  J Socioeconomic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2005;56 (2) 139- 146
PubMed
52.
Cooper-Patrick  LGallo  JJGonzales  JJ  et al.  Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282 (6) 583- 589
PubMed
53.
Wachtler  CBrorsson  ATroein  M Meeting and treating cultural difference in primary care: a qualitative interview study. Fam Pract 2006;23 (1) 111- 115
PubMed
54.
Davey Smith  GNeaton  JDWentworth  DStamler  RStamler  Jfor the Multiple Risk Factor Intervention Trial Research Group, Mortality differences between black and white men in the USA: contribution of income and other risk factors among men screened for the MRFIT. Lancet 1998;351 (9107) 934- 939
PubMed
55.
Lin  CCRogot  EJohnson  NJSorlie  PDArias  E A further study of life expectancy by socioeconomic factors in the National Longitudinal Mortality Study. Ethn Dis 2003;13 (2) 240- 247
PubMed
56.
Ng-Mak  DSDohrenwend  BPAbraido-Lanza  AFTurner  JB A further analysis of race differences in the National Longitudinal Mortality Study. Am J Public Health 1999;89 (11) 1748- 1751
PubMed
57.
Kessler  RC McGonagle  KAZhao  S  et al.  Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51 (1) 8- 19
PubMed
58.
Mauksch  LBTucker  SMKaton  WJ  et al.  Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract 2001;50 (1) 41- 47
PubMed
59.
Saha  SKomaromy  MKoepsell  TDBindman  AB Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med 1999;159 (9) 997- 1004
PubMed
60.
Gold  RMichael  YLWhitlock  EP  et al.  Race/ethnicity, socioeconomic status, and lifetime morbidity burden in the Women's Health Initiative: a cross-sectional analysis. J Womens Health (Larchmt) 2006;15 (10) 1161- 1173
PubMed
61.
Greenlund  KJKeenan  NLGiles  WH  et al.  Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001. Am Heart J 2004;147 (6) 1010- 1016
PubMed
62.
Greenlund  KJNeff  LJZheng  ZJ  et al.  Low public recognition of major stroke symptoms. Am J Prev Med 2003;25 (4) 315- 319
PubMed
63.
Neumann  MWirtz  MBollschweiler  E  et al.  Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modelling approach. Patient Educ Couns 2007;69 (1-3) 63- 75
PubMed
64.
Fiscella  KMeldrum  SFranks  P  et al.  Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care 2004;42 (11) 1049- 1055
PubMed
65.
Johnson  RLSaha  SArbelaez  JJBeach  MCCooper  LA Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004;19 (2) 101- 110
PubMed
66.
Hutton  CGunn  J Do longer consultations improve the management of psychological problems in general practice? a systematic literature review. BMC Health Serv Res 2007;771
PubMed10.1186/1472-6963-7-71
67.
Moore  CGProbst  JCTompkins  MCuffe  SMartin  AB The prevalence of violent disagreements in US families: effects of residence, race/ethnicity, and parental stress. Pediatrics 2007;119 ((suppl 1)) S68- S76
PubMed
68.
Fiscella  KFranks  P Does psychological distress contribute to racial and socioeconomic disparities in mortality? Soc Sci Med 1997;45 (12) 1805- 1809
PubMed
69.
Kleinman  ABenson  P Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Med 2006;3 (10) e294
PubMed
70.
Franks  PFiscella  KMeldrum  S Racial disparities in the content of primary care office visits. J Gen Intern Med 2005;20 (7) 599- 603
PubMed
71.
Wei  WFindley  PASambamoorthi  U Disability and receipt of clinical preventive services among women. Womens Health Issues 2006;16 (6) 286- 296
PubMed
72.
Maly  RCLeake  BSilliman  RA Health care disparities in older patients with breast carcinoma: informational support from physicians. Cancer 2003;97 (6) 1517- 1527
PubMed
73.
Brandon  DTIsaac  LALaveist  TA The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc 2005;97 (7) 951- 956
PubMed
74.
Murray  EPollack  LWhite  MLo  B Clinical decision-making: patients' preferences and experiences. Patient Educ Couns 2007;65 (2) 189- 196
PubMed
75.
Young  ASKlap  RSherbourne  CDWells  KB The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry 2001;58 (1) 55- 61
PubMed
76.
Mercer  SWFitzpatrick  BGourlay  GVojt  G McConnachie  AWatt  GCM More time for complex consultations in a high-deprivation practice is associated with increased patient enablement. Br J Gen Pract 2007;57 (545) 960- 966
PubMed
77.
Parchman  MLPugh  JARomero  RLBowers  KW Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med 2007;5 (3) 196- 201
PubMed
78.
Parchman  MLRomero  RLPugh  JA Encounters by patients with type 2 diabetes—complex and demanding: an observational study. Ann Fam Med 2006;4 (1) 40- 45
PubMed
79.
Burgess  DJFu  SSvan Ryn  M Why do providers contribute to disparities and what can be done about it? J Gen Intern Med 2004;19 (11) 1154- 1159
PubMed
80.
Rohrer  JEXu  KTBickley  L Duration of heart disease visits by elderly patients: productivity versus quality. Health Serv Manage Res 2002;15 (3) 141- 146
PubMed
81.
Dugdale  DCEpstein  RPantilat  SZ Time and the patient-physician relationship. J Gen Intern Med 1999;14 ((suppl 1)) S34- S40
PubMed
82.
Blumenthal  DCausino  NChang  YC  et al.  The duration of ambulatory visits to physicians. J Fam Pract 1999;48 (4) 264- 271
PubMed
83.
Berlowitz  DRAsh  ASGlickman  M  et al.  Developing a quality measure for clinical inertia in diabetes care. Health Serv Res 2005;40 (6, pt 1) 1836- 1853
PubMed
84.
O’Connor  PJ Overcome clinical inertia to control systolic blood pressure. Arch Intern Med 2003;163 (22) 2677- 2678
PubMed
85.
Grant  RWPirraglia  PAMeigs  JBSinger  DE Trends in complexity of diabetes care in the United States from 1991 to 2000. Arch Intern Med 2004;164 (10) 1134- 1139
PubMed
86.
Grant  RAdams  ASTrinacty  CM  et al.  Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care 2007;30 (4) 807- 812
PubMed
87.
Hicks  PCWestfall  JMVan Vorst  RF  et al.  Action or inaction? decision making in patients with diabetes and elevated blood pressure in primary care. Diabetes Care 2006;29 (12) 2580- 2585
PubMed
88.
Green  ARCarney  DRPallin  DJ  et al.  Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 2007;22 (9) 1231- 1238
PubMed
89.
Schulman  KABerlin  JAHarless  W  et al.  The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340 (8) 618- 626
PubMed
90.
McGuire  TGAyanian  JZFord  DEHenke  REMRost  KMZaslavsky  AM Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care. Health Serv Res 2008;43 (2) 531- 551
PubMed
91.
Groopman  J How Doctors Think.  New York, NY Houghton-Mifflin Co2007;
92.
Beach  MCRosner  MCooper  LADuggan  PSShatzer  J Can patient-centered attitudes reduce racial and ethnic disparities in care? Acad Med 2007;82 (2) 193- 198
PubMed
93.
Fiscella  KGoodwin  MAStange  KC Does patient educational level affect office visits to family physicians? J Natl Med Assoc 2002;94 (3) 157- 165
PubMed
94.
Wilson  IBKaplan  S Physician-patient communication in HIV disease: the importance of patient, physician, and visit characteristics. J Acquir Immune Defic Syndr 2000;25 (5) 417- 425
PubMed
95.
Schneider  JKaplan  SHGreenfield  SLi  WWilson  IB Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med 2004;19 (11) 1096- 1103
PubMed
96.
Eaton  CBGoodwin  MAStange  KC Direct observation of nutrition counseling in community family practice. Am J Prev Med 2002;23 (3) 174- 179
PubMed
97.
Tamblyn  RBerkson  LDauphinee  WD  et al.  Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med 1997;127 (6) 429- 438
PubMed
98.
Gotler  RSFlocke  SAGoodwin  MAZyzanski  SJMurray  THStange  KC Facilitating participatory decision-making: what happens in real-world community practice? Med Care 2000;38 (12) 1200- 1209
PubMed
99.
Kaplan  RCBhalodkar  NCBrown  EJ  JrWhite  JBrown  DL Race, ethnicity, and sociocultural characteristics predict noncompliance with lipid-lowering medications. Prev Med 2004;39 (6) 1249- 1255
PubMed
100.
Bosworth  HBDudley  TOlsen  MK  et al.  Racial differences in blood pressure control: potential explanatory factors. Am J Med 2006;119 (1) 70.e9- 70.e15http://www.amjmed.com/article/PIIS0002934305007515/fulltext
101.
Pappas  GHadden  WCKozak  LJFisher  GF Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups. Am J Public Health 1997;87 (5) 811- 816
PubMed
102.
Gupta  RSCarrion-Carire  VWeiss  KB The widening black/white gap in asthma hospitalizations and mortality. J Allergy Clin Immunol 2006;117 (2) 351- 358
PubMed
103.
Probst  JCGreenhouse  DLSelassie  AW Patient and physician satisfaction with an outpatient care visit. J Fam Pract 1997;45 (5) 418- 425
PubMed
104.
Singer  JDDavidson  SMGraham  SDavidson  HS Physician retention in community and migrant health centers: who stays and for how long? Med Care 1998;36 (8) 1198- 1213
PubMed
105.
Iglehart  JK Changing health insurance trends. N Engl J Med 2002;347 (12) 956- 962
PubMed
106.
Goodson  JD Unintended consequences of resource-based relative value scale reimbursement. JAMA 2007;298 (19) 2308- 2310
PubMed
107.
Chao  JGillanders  WGFlocke  SAGoodwin  MAKikano  GEStange  KC Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract 1998;47 (1) 28- 32
PubMed
108.
Miller  RHWest  CBrown  TMSim  IGanchoff  C The value of electronic health records in solo or small group practices. Health Aff (Millwood) 2005;24 (5) 1127- 1137
PubMed
109.
Menachemi  NMatthews  MCFord  EWBrooks  RG The influence of payer mix on electronic health record adoption by physicians. Health Care Manage Rev 2007;32 (2) 111- 118
PubMed
110.
Shields  AEShin  PLeu  MG  et al.  Adoption of health information technology in community health centers: results of a national survey. Health Aff (Millwood) 2007;26 (5) 1373- 1383
PubMed
111.
Clancy  DEHuang  POkonofua  EYeager  DMagruder  KM Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med 2007;22 (5) 620- 624
PubMed
112.
Kawasaki  LMuntner  PHyre  ADHampton  KDeSalvo  KN Willingness to attend group visits for hypertension treatment. Am J Manag Care 2007;13 (5) 257- 262
PubMed
113.
Sia  CTonniges  TFOsterhus  ETaba  S History of the medical home concept. Pediatrics 2004;113 (5) ((suppl)) 1473- 1478
PubMed
114.
Kellerman  RKirk  L Principles of the patient-centered medical home. Am Fam Physician 2007;76 (6) 774- 775
PubMed
115.
Goroll  AHBerenson  RASchoenbaum  SCGardner  LB Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med 2007;22 (3) 410- 415
PubMed
116.
Yano  EMSimon  BFLanto  ABRubenstein  LV The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality transformation. Am J Public Health 2007;97 (12) 2151- 2159
PubMed
117.
Audet  AMDavis  KSchoenbaum  SC Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med 2006;166 (7) 754- 759
PubMed
118.
Liu  CFFortney  JVivell  S  et al.  Time allocation and caseload capacity in telephone depression care management. Am J Manag Care 2007;13 (12) 652- 660
PubMed
119.
Denberg  TDRoss  SESteiner  JF Patient acceptance of a novel preventive care delivery system. Prev Med 2007;44 (6) 543- 546
PubMed
120.
Dietrich  AJTobin  JNCassells  A  et al.  Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial. Ann Intern Med 2006;144 (8) 563- 571
PubMed
121.
Pyper  CAmery  JWatson  MCrook  C Access to electronic health records in primary care: a survey of patients' views. Med Sci Monit 2004;10 (11) SR17- SR22
PubMed
122.
Gustafson  DH McTavish  FMStengle  W  et al.  Use and impact of e-health system by low-income women with breast cancer. J Health Commun 2005;10 ((suppl 1)) 195- 218
PubMed
123.
Kaplan  SH Patient reports of health status as predictors of physiologic health measures in chronic disease. J Chronic Dis 1987;40 ((suppl 1)) 27S- 40S
PubMed
124.
Gerber  BSBrodsky  IGLawless  KA  et al.  Implementation and evaluation of a low-literacy diabetes education computer multimedia application. Diabetes Care 2005;28 (7) 1574- 1580
PubMed
125.
Bodenheimer  TLaing  BY The teamlet model of primary care. Ann Fam Med 2007;5 (5) 457- 461
PubMed
126.
McKibben  LJStange  PVSneller  VPStrikas  RARodewald  LEfor the Advisory Committee on Immunization Practices, Use of standing orders programs to increase adult vaccination rates. MMWR Recomm Rep 2000;49 (RR-1) 15- 16
PubMed
127.
Paasche-Orlow  MKRiekert  KABilderback  A  et al.  Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med 2005;172 (8) 980- 986
PubMed
128.
Freeman  HP Patient navigation: a community based strategy to reduce cancer disparities. J Urban Health 2006;83 (2) 139- 141
PubMed
129.
Bradford  JBColeman  SCunningham  W HIV System Navigation: an emerging model to improve HIV care access. AIDS Patient Care STDS 2007;21 ((suppl 1)) S49- S58
PubMed
130.
Fiscella  KGeiger  HJ Health information technology and quality improvement for community health centers. Health Aff (Millwood) 2006;25 (2) 405- 412
PubMed
131.
Neuwirth  EBSchmittdiel  JATallman  KBellows  J Understanding panel management: comparative case studies of an emerging approach to population care. Permanente J 2008;11 (3) 11- 24
132.
Rudd  PMiller  NHKaufman  J  et al.  Nurse management for hypertension: a systems approach. Am J Hypertens 2004;17 (10) 921- 927
PubMed
133.
Fiscella  KShin  P The inverse care law: implications for healthcare of vulnerable populations. J Ambul Care Manage 2005;28 (4) 304- 312
PubMed
134.
Bodenheimer  T Coordinating care: a major (unreimbursed) task of primary care. Ann Intern Med 2007;147 (10) 730- 731
PubMed
135.
Institute of Medicine, Crossing the Quality Chasm: a New Health System for the 21st Century.  Washington, DC National Academy Press2001;
136.
Blustein  J Who is accountable for racial equity in health care? JAMA 2008;299 (7) 814- 816
PubMed
137.
Hasnain-Wynia  RBaker  DW Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res 2006;41 (4, pt 1) 1501- 1518
PubMed
138.
Fiscella  KFremont  AM Use of geocoding and surname analysis to estimate race and ethnicity. Health Serv Res 2006;41 (4, pt 1) 1482- 1500
PubMed
139.
Bajekal  MAlves  BJarman  BHurwitz  B Rationale for the new GP deprivation payment scheme in England: effects of moving from electoral ward to enumeration district underprivileged area scores. Br J Gen Pract 2001;51 (467) 451- 455
PubMed
140.
Verheij  RADe Bakker  DHReijneveld  SA GP income in relation to workload in deprived urban areas in the Netherlands: before and after the 1996 pay review. Eur J Public Health 2001;11 (3) 264- 266
PubMed
141.
Sundquist  KMalmstrom  MJohansson  SESundquist  J Care Need Index: a useful tool for the distribution of primary health care resources. J Epidemiol Community Health 2003;57 (5) 347- 352
PubMed
142.
Casalino  LPElster  A Will pay-for-performance and quality reporting affect health care disparities? [published correction appears in Health Aff (Milwood). 2007;26(6):1794]. Health Aff (Millwood) 2007;26 (3) w405- w414
PubMed
143.
Rosenthal  TCHorwitz  MESnyder  GO’Connor  J Medicaid primary care services in New York state: partial capitation vs full capitation. J Fam Pract 1996;42 (4) 362- 368
PubMed
144.
Weissman  JSBetancourt  JCampbell  EG  et al.  Resident physicians' preparedness to provide cross-cultural care. JAMA 2005;294 (9) 1058- 1067
PubMed
145.
Smith  WRBetancourt  JRWynia  MK  et al.  Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med 2007;147 (9) 654- 665
PubMed
146.
Maguire  PFaulkner  ABooth  KElliott  CHillier  V Helping cancer patients disclose their concerns. Eur J Cancer 1996;32A (1) 78- 81
PubMed
147.
Heritage  JRobinson  JDElliott  MNBeckett  MWilkes  M Reducing patients unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007;22 (10) 1429- 1433
PubMed
148.
Mauksch  LBHillenburg  LRobins  L The establishing focus protocol: training for collaborative agenda setting and time management in the medical review. Fam Syst Health 2001;19147- 157
149.
Lewin  SASkea  ZCEntwistle  VDick  JZwarenstein  M Interventions for Providers to Promote a Patient-Centered Approach in Clinical Consultations.  Oxford, England Update Software2001;
150.
Smith  RCMettler  JAStoffelmayr  BE  et al.  Improving residents' confidence in using psychosocial skills. J Gen Intern Med 1995;10 (6) 315- 320
PubMed
151.
Brown  RFButow  PNDunn  SMTattersall  MH Promoting patient participation and shortening cancer consultations: a randomised trial. Br J Cancer 2001;85 (9) 1273- 1279
PubMed
152.
Kripalani  SBussey-Jones  JKatz  MGGenao  I A prescription for cultural competence in medical education. J Gen Intern Med 2006;21 (10) 1116- 1120
PubMed
153.
Betancourt  JR Cultural competence: marginal or mainstream movement? N Engl J Med 2004;351 (10) 953- 955
PubMed
154.
Murray  MBodenheimer  TRittenhouse  DGrumbach  K Improving timely access to primary care: case studies of the advanced access model. JAMA 2003;289 (8) 1042- 1046
PubMed
155.
O’Connor  MEMatthews  BSGao  D Effect of open access scheduling on missed appointments, immunizations, and continuity of care for infant well-child care visits. Arch Pediatr Adolesc Med 2006;160 (9) 889- 893
PubMed
156.
Ludman  EJSimon  GETutty  SVon Korff  M A randomized trial of telephone psychotherapy and pharmacotherapy for depression: continuation and durability of effects. J Consult Clin Psychol 2007;75 (2) 257- 266
PubMed
157.
An  LCZhu  SHNelson  DB  et al.  Benefits of telephone care over primary care for smoking cessation: a randomized trial. Arch Intern Med 2006;166 (5) 536- 542
PubMed
158.
O’Malley  AJLandon  BEGuadagnoli  E Analyzing multiple informant data from an evaluation of the health disparities collaboratives. Health Serv Res 2007;42 (1 pt 1) 146- 164
PubMed
159.
Szilagyi  PGSchaffer  SShone  L  et al.  Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics 2002;110 (5) e58
PubMed10.1542/peds.110.5.e58
160.
Landon  BEHicks  LSO’Malley  AJ  et al.  Improving the management of chronic disease at community health centers. N Engl J Med 2007;356 (9) 921- 934
PubMed
161.
Batalden  PBMohr  JJNelson  EC  et al.  Continually improving the health and value of health care for a population of patients: the panel management process. Qual Manag Health Care 1997;5 (3) 41- 51
PubMed
162.
Hypertension Detection and Follow-up Program Cooperative Group, Five-year findings of the hypertension detection and follow-up program, II: mortality by race-sex and age. JAMA 1979;242 (23) 2572- 2577
PubMed
163.
Multiple Risk Factor Intervention Trial Research Group, Mortality rates after 10.5 years for participants in the Multiple Risk Factor Intervention Trial: findings related to a priori hypotheses of the trial. JAMA 1990;263 (13) 1795- 1801
PubMed
164.
Goldman  DPSmith  JP Can patient self-management help explain the SES health gradient? Proc Natl Acad Sci U S A 2002;99 (16) 10929- 10934
PubMed
165.
Bodenheimer  TLorig  KHolman  HGrumbach  K Patient self-management of chronic disease in primary care. JAMA 2002;288 (19) 2469- 2475
PubMed
166.
O’Connor  AMBennett  CStacey  D  et al.  Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? a systematic review and meta-analysis. Med Decis Making 2007;27 (5) 554- 574
PubMed
167.
Gilbody  SBower  PFletcher  JRichards  DSutton  AJ Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006;166 (21) 2314- 2321
PubMed
168.
Karliner  LSJacobs  EAChen  AHMutha  S Do professional interpreters improve clinical care for patients with limited English proficiency? a systematic review of the literature. Health Serv Res 2007;42 (2) 727- 754
PubMed
169.
Jandorf  LGutierrez  YLopez  JChristie  JItzkowitz  SH Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. J Urban Health 2005;82 (2) 216- 224
PubMed
170.
Ell  KVourlekis  BLee  PJXie  B Patient navigation and case management following an abnormal mammogram: a randomized clinical trial. Prev Med 2007;44 (1) 26- 33
PubMed
171.
Gardner  LIMetsch  LRAnderson-Mahoney  P  et al.  Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS 2005;19 (4) 423- 431
PubMed
172.
Nagykaldi  ZMold  JWAspy  CB Practice facilitators: a review of the literature. Fam Med 2005;37 (8) 581- 588
PubMed
173.
Greenfield  SKaplan  SWare  JE  Jr Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med 1985;102 (4) 520- 528
PubMed
174.
Brown  RButow  PNBoyer  MJTattersall  MH Promoting patient participation in the cancer consultation: evaluation of a prompt sheet and coaching in question-asking. Br J Cancer 1999;80 (1-2) 242- 248
PubMed
175.
Williams  GC McGregor  HAZeldman  AFreedman  ZRDeci  EL Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychol 2004;23 (1) 58- 66
PubMed
176.
Oliver  JWKravitz  RLKaplan  SHMeyers  FJ Individualized patient education and coaching to improve pain control among cancer outpatients. J Clin Oncol 2001;19 (8) 2206- 2212
PubMed
177.
Greenfield  SKaplan  SHWare  JE  JrYano  EMFrank  HJ Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3 (5) 448- 457
PubMed
178.
Roter  DL Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction, and compliance. Health Educ Monogr 1977;5 (4) 281- 315
PubMed
179.
Crabtree  BFMiller  WLTallia  AF  et al.  Delivery of clinical preventive services in family medicine offices. Ann Fam Med 2005;3 (5) 430- 435
PubMed
180.
Institute of Medicine, Envisioning the National Health Care Quality Report.  Washington, DC National Academy Press2001;
×