President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Strengthening the Market to Improve Quality

Chapter Eight
Focusing on Vulnerable Populations

Throughout its work, the Commission has been particularly cognizant of the special concerns associated with ensuring quality health care for vulnerable populations. Individuals may be vulnerable to health care quality problems for one or a combination of underlying reasons, including those pertaining to their financial circumstances or place of residence; health, age, or functional or developmental status; or ability to communicate effectively. Other personal characteristics, such as race, ethnicity, and sex, also have been shown to be associated with differential experiences in obtaining quality health care. Furthermore, characteristics of the evolving health system -- such as an eroding safety net -- can interact with personal characteristics to contribute to vulnerability.

There is a clear need to increase the level of attention paid to vulnerable groups, including both those who, because of their chronic illness or disability, have many interactions with the health system, and those who have difficulty accessing the system and may be most likely to fall through the cracks during this period of rapid health system change. In the Consumer Bill of Rights and Responsibilities, the Commission articulated that consumers have the right to considerate, respectful care, free of discrimination. In this chapter, the Commission extends this work by specifically addressing ways in which the particular needs of vulnerable populations should be accounted for in the design of systems for health care delivery, quality measurement, and payment.


Sources of Vulnerability

Several specific groups within the population have been shown to be especially vulnerable to health care quality problems, differential experiences in the health system, or increased burden of poor health. Among others, these groups include the uninsured, the poor, the elderly, children, those living with mental or physical disabilities, racial and ethnic minorities, and the terminally ill. The vulnerability that these groups experience usually can be attributed to one or some combination of three factors: economic status or geographic location; health, functional, or developmental status; or ability to communicate. Not all sources of vulnerability can be fully explained by these factors, however, raising important questions for further research.

Implications for the Health System

Understanding the underlying sources of vulnerability is critical, not only because of the need to influence the development of targeted quality improvement efforts, but also because addressing the problems vulnerable groups encounter requires coordinated efforts throughout the health system. In particular, populations vulnerable to health care quality problems need to be accounted for in the design of effective systems for health care delivery, the choice of appropriate health care quality measures, and the adaptation of payment mechanisms.


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  1. This review focused on terminally ill individuals, children with special needs, people with mental illness, and the frail elderly.

  2. For some individuals with severe mental illness, community-based care was not appropriate and inpatient care remains necessary.

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Last Revised: Sunday, July 19, 1998