Strategies to Reduce Health Disparities

Ensuring Quality

Presenters: David R. Nerenz, Ph.D., Professor, College of Human Medicine, Director, Health Care Studies, Institute for Managed Care, Michigan State University, East Lansing, MI Patricia MacTaggart, M.B.A., Director, Plan Improvement and Quality, Center for Health Plans and Providers, Health Care Financing Administration (HCFA), U.S. Department of Health and Human Services, Baltimore, MD

Managed care organizations (MCOs) can serve as catalysts for quality improvement, but face several barriers to focusing on disparities:

• The priority given to disparity issues by purchasers (as MCOs serve as the agents of purchasers and, therefore, do not set priorities on their own).
• Community concerns about MCOs having data on race/ethnicity of members.
• Belief that it is illegal for MCOs to have data on race/ethnicity of members.
• MCOs lack of data on race/ethnicity.

It is legal for MCOs to have data on race/ethnicity. Federal laws (including Title VI and HCFA regulations) do not place restrictions on collecting these data. Only four States (California, Maryland, New Hampshire, and New Jersey) have legal barriers.

The Report Card on Health Care for Minority Populations, supported by the Commonwealth Fund, is designed to measure MCO performance specifically by race/ethnicity. The Report Card includes quality measures in:

• Preventive services.
• Care of chronic conditions.
• Satisfaction.
• Cultural/linguistic competence.

Phase I

Phase I, which ran from May 1998 to December 1999, included planning and pilot testing. Objectives were to recommend:

• A set of health care concepts, measures, and clinical conditions that would be feasible to include in a report card.
• Policies and procedures for collecting and reporting report card data.

Collaborating MCOs/providers were Henry Ford Health System (Detroit, Michigan), Memorial Hermann Healthcare System (Houston, Texas), and Lovelace Clinic Foundation (Albuquerque, New Mexico). In the next part of this phase:

• Three advisory panels (technical, black community leaders, and Hispanic community leaders), as well as representatives of the three MCOs, were established.
• The panels discussed measures, set priorities, and determined the process for pilot testing.
• Then pilot studies were conducted, including studies using the Health Plan Employer Data and Information Set (HEDIS®) and studies on asthma, diabetes, cultural and linguistic competence, and chemotherapy.

After completion of the pilot studies, the proposed measures for the Report Card focus on:

• HEDIS® effectiveness-of-care measures and the Consumer Assessment of Health Plans (CAHPS®) survey.
• Cultural and linguistic competence.
• High-prevalence diseases (i.e., asthma, diabetes).
• Adequacy of information and involvement in decisionmaking for patients with serious illness (i.e., prostate cancer).

For example, the cultural and linguistic competence measures include:

• The percent of black and Hispanic physicians, and the diversity of MCO and clinical staff, relative to the ethnic population(s) served.
• Training in cultural competence available to the clinical staff and physicians.
• Whether an MCO conducts a member survey on satisfaction with communication and language issues.
• The percent of Spanish-speaking physicians and availability of interpreter services through AT&T, clinic, or MCO staff in areas with a large Spanish-speaking population.
• Availability of information in Spanish describing treatment options and of bilingual forms and educational materials.
• List of providers given to members to make their choices includes information about other languages spoken by a provider.

Phase II

Phase II, running from May 2000 until December 2001, is a demonstration project to further assess the feasibility and potential value of the minority health care report card. Nine MCOs are involved in testing various parts of the proposed measure set. Key questions include:

• Can MCOs collect data on race/ethnicity?
• Can MCOs produce reports in which quality of care information is reported separately by race/ethnicity?
• How much within-MCO variation is observed across groups on various measures? How much across-MCO variation is observed across groups on various measures?
• When can information on race/ethnicity be collected?
• How should information be collected?
• From whom?

Data on race/ethnicity will be obtained from:

• Employers or public purchasers (e.g., Medicaid) during the enrollment process.
• Individual MCO members after enrollment.
• Provider databases.
• Encounter records or claims.
• Medical records.
• Proxy from other existing data (e.g., geocoding using address information).

Once Phase II has been completed and the feasibility and usefulness of the Report Card analyzed, it is possible that the National Committee for Quality Assurance or the Health Care Financing Administration (HCFA) could institutionalize the process. Currently, HCFA is implementing other efforts to improve the quality of care provided to racial/ethnic minorities.

Each year, HCFA requires Medicare+Choice (M+C) organizations to complete quality improvement projects under the Quality Assurance and Performance Improvement (QAPI) program. Two QAPI options will be available for M+C organizations for 2003: Clinical Health Care Disparities and Culturally and Linguistically Appropriate Services (CLAS).

HCFA intends to provide nonclinical options for addressing culturally and linguistically appropriate services. Specifications will be provided to the M+C organizations by means of an Operations Policy Letter. HCFA intends to create the framework, then M+C organizations will design systems within that framework to meet the QAPI goals. This framework has been developed through three meetings with representatives from industry, physicians, and experts. The draft Operations Policy Letter will be distributed for broader review and input in Spring 2001.

Technical assistance tools will be developed and distributed prior to implementation by collaborating Federal agencies. Technical assistance will be provided regarding:

• The delivery of culturally and linguistically appropriate services.
• Oral language assistance.
• Mechanisms and tools for collections of ethnicity information for identifications.
• Best practices.

The proposed CLAS Projects Framework includes the following steps:

• Selecting a nonclinical topic that addresses "organizational support" or "language access."
• Identifying an opportunity for improvement.
• Developing and/or conducting meaningful interventions (as determined by the M+C organization).
• Determining if the opportunity for improvement or goal has been achieved through structural/process measures.
• Reviewing 1 year later to ensure that the benchmark or goal has been sustained.

Issues in implementing this initiative include:

• Burden and cost to both physicians and M+C organizations.
• Fitting data requirements with those of other Federal initiatives.
• Methodological issues, such as the grouping of categories in the Social Security database.

Additional Resources

Fiscella K, Franks P, Gold MR, Clancy CM, et al. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000;283(19):2579-84.

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