What Can Primary Care Practices Do to Reduce Disparities?
By Molly Totman, MPH, Vice President of Quality & Engagement
(March 2026)
Earlier this month, MHQP released results from its 2025 statewide Patient Experience Survey which revealed widening racial disparities among commercially insured patients in two areas central to high quality primary care — Behavioral Health Screening and Self-Management Support. These domains are critical because they capture whether a patient reports that someone in their clinician’s office screened them for depression and anxiety or helped them set goals and address barriers to managing their health.
While results in these areas improved across the state in 2025 for White patients, the disparity gap widened for Black and Asian patients in both domains.
In the wake of this and other reports MHQP has published about persistent disparities in care experiences in Massachusetts, the most common question we receive from primary care practices is: “What specifically can we do to help address these issues?”
That’s where improvement science comes in. As a public health professional with many years of experience leading quality improvement initiatives, I’d like to suggest some specific steps practices can take to address these disparities in care.
The first step is to examine whether disparities in behavioral health screening and response, self-management support, and social needs screening exist within the practice or organization. This can be assessed by reviewing available patient experience survey data, including annual MHQP PES data and/or internal quality improvement survey data, and clinical measure performance (e.g., depression screening). Stratify data by race, ethnicity, language, and any other relevant factors. Compare performance across clinician teams and practice locations to uncover any patterns.
If low performance and/or disparities in performance are detected, the next step would be to establish a project charter or A3 template, a guiding document for your improvement work. Your guiding document should identify core improvement team members, stakeholders (including patients and families), a problem statement, aim statement, and improvement measures (with equity focus as identified in data). You will also use this document to track your improvement work over time.
Then, conduct root cause analyses to identify drivers of disparities and low performance. Consider:
- Using process maps or flow charts to understand where the current system/workflows may be driving inconsistent experiences or outcomes.
- Conducting focus groups or interviews with patients, families, and staff to understand and document lived experiences, structural barriers, and what is working locally.
- Utilizing 5 Whys to pinpoint the cause of a specific issue.
Based on your root cause analyses, identify your areas of change/intervention that will most likely lead to improvement. Consider developing a theory of change and plan your tests of change/interventions (start small).
Once these steps are complete, it’s time to implement your change and study the impact of your change across your identified measures, towards your aim. If your changes result in an improvement, continue to scale with adaptations needed. If your changes don’t result in an improvement, it may be time to adapt or abandon your focus and move to the next change idea. Consider using Run Charts or Control Charts for quantitative data.
Don’t forget to celebrate your team’s successes! And be sure to integrate any changes into standard protocols or job aids to ensure sustainability.
The steps outlined above are intended as practical guidance for those leading improvement work within practices and health systems. MHQP’s role as an independent nonprofit organization is to support those efforts by measuring, analyzing, and reporting on patients’ experiences of care — including ensuring that equity-focused data are available to practices, health plans, policymakers, and the public.
Remember: disparities in care experiences are deeply rooted, making them challenging to address. However, this work is essential. By establishing clear goals and intentions, primary care practices can take small, meaningful steps that will collectively lead to significant change.