Date of Award


Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Mark Schlesinger


Objective. To use Casalino et al.’s (2007) proposed causal pathways of how pay-for-performance (P4P) can exacerbate racial/ethnic health care disparities as a framework for analyzing the literature and determine the adequacy of the evidence.

Data Sources/Study Setting. Existing literature (gray and peer-reviewed) on pay-for-performance and racial/ethnic health disparities identified from the Ovid Medline database.

Conceptual Framework. Casalino et al.’s four casual pathways include: “Pathway 1: Reduction in income for physicians in poor minority communities,” “Pathway 2: ‘Color-blind’ quality improvement programs,” “Pathway 3: ‘Teaching to the test’ might disproportionately affect minorities,” and “Pathway 4: Avoiding patients perceived as likely to lower quality scores.”

Principal Findings. For Pathway 1, there is consistent and strong evidence of harm. With a reduction in income for physicians in poor minority community settings, communities and their patients are being harmed. For Pathway 2, there is a lack of evidence. However, despite this, statistics from outside the P4P literature are consistent in their findings that “color-blind” approaches are occurring in health care. For Pathway 3, there is consistent and strong evidence of neglect. “Teaching to the test” is occurring, and existing P4P programs do not incorporate metrics that can improve disparities. Lastly, for Pathway 4, there is qualitative and quantitative evidence, but it is inconclusive. Some studies report avoidance whereas others do not.

Conclusion. Our health care system must step up to the challenge of accounting for differences in patient populations in payment models, such as P4P programs. If we do not, racial and ethnic minority patients will continue to suffer as structural inequities built into these programs persist.

Key Words. Pay-for-performance, racial and ethnic health care disparities, health policy


This is an Open Access Thesis.

Open Access

This Article is Open Access