Health Disparities and PCMH: Equity Through Quality Measurement

March 11, 2019 · NCQA Communications

Health Care is important no matter who you are or where you come from. Unfortunately, the quality of that care can vary wildly depending on several different factors. This leads to disparities in health outcomes for the most vulnerable patients, diminished quality scores and high costs.

This is why it is so important to talk about these issues in the health care system. A health disparity is defined as a particular type of health difference that is closely linked with social, economic or environmental disadvantages. These disparities tend to impact groups who have systematically faced more obstacles due to their race/ethnicity, religion, socioeconomic status, gender, age, mental health, sexual orientation, or other characteristics linked to discrimination or marginalization. Not only can these populations suffer from devastating circumstances like homelessness or food insecurity, but these conditions lead to worse outcomes and lower quality scores which impact plans and providers as well.

This isn’t just a cost issue or a health care issue, it’s a moral issue. We think we can help.

At NCQA, our PCMH’s focus on quality primary care for all different populations. In order to become a PCMH, practices must meet several different standards to address the critical needs driven by these disparities-known as social determinants of health. PCMHs focus on an individuals’ needs and preferences by developing long term partnerships rather than quick, random visits. They provide greater access to care through expanded after hours care and electronic mediums of communication.


How It Works

The PCMH program includes 100 distinct standards in six categories:

  1. Knowing and Managing You Patients
  2. Patient-Centered Access and Continuity
  3. Care Management and Support
  4. Performance Measurement and Quality Improvement
  5. Care Coordination and Transitions
  6. Team-Based Care and Practice Organization


In a recently released White Paper, we describe the core requirements essential to becoming a PCMH. We also describe the “elective” requirements meant to enhance the core set of standards. This paper also looks at PCMHs address disparities by:

  • Looking at patient populations to identify disparities and the factors that drive them
  • Working with specific patients to address these factors
  • Tracking progress on these goals to reduce and ultimately eliminate disparities


This will not be an easy task. Since health disparities are caused by more than just a patient’s health decisions, it will take more than just the health care sector to tackle these issues. But we can start by doing our part first.

If you want to learn even more about how the PCMH program adresses disparities, be sure to register for our webinar this Friday at 1PM!

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