Chapter V. Intervening to Reduce Disparities
Launching pilot interventions intended to reduce racial and
ethnic disparities was one of the four main areas of Collaborative focused on
(bold type in Figure V.1). Because most of Phase I was devoted to
geocoding and data collection, most firms began to develop pilot interventions
only during the last six months of the Collaborative. This chapter discusses
the role of the pilot interventions in the Collaborative and how expectations
for interventions changed over time; the interventions themselves; challenges
facing the firms as they implemented the interventions, and the role and
significance of the pilot interventions to the firms.
A. Summary of Findings
During most of the Collaborative, the firms' efforts to
implement interventions to reduce disparities took a back seat to data
collection. As firms gained insight into disparities, they began to think more
concretely about what they, as entities sponsoring health plans with different
business practices, could do to reduce disparities. By the end of the
Collaborative, seven of the nine firms had either completed or were in the
process of completing pilot interventions, and two were in the process of
developing them. Consistent with the agreed-upon Collaborative focus, diabetes
in racial/ethnic minorities was the primary target of all pilot interventions,
and four of the firms geared their interventions toward Hispanics and the
others focused on other subgroups. Most pilots were small, though size varied
by firm, and the interventions themselves varied markedly from one firm to the
next. While it was too early at the time of this writing for most firms to
know the outcomes of their interventions, most perceived them as creating a
framework for future expansion and learning and planned to pursue related
interventions even though Phase I was ending.
The firm's progress in developing interventions was
challenging for a variety of reasons. First, firms were not sure where to
begin, citing uncertainty about how to best intervene. Second, lack of data
was a constraint for many firms because the ability to develop an appropriate
intervention means having an understanding of the race/ethnicity of particular members and an ability to
geographically target those members. Third, the scale and complexity of the
firms themselves made it difficult to implement effective interventions because
of the need to coordinate activities in the face of the split between corporate
and regional responsibilities and between the various departments and other
functional areas in the firm. Fourth, logistical issues, such as recruiting
physicians to participate in provider-based interventions, were a challenge.
The Collaborative led firms to view their work on disparities
as a part of their quality improvement effort rather than as an add-on or
separate activity. This link created leverage to address disparities within
firms. Still, firms were constrained by the tight fiscal environment in which
they operated and by competition for resources. The ability to build a
business case for addressing disparities was viewed by firms as important to
obtaining the resources needed to address the quality improvement agenda and
disparities in health care.
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B. Expectations for Interventions Changed Over Time
From the start, expectations for the Collaborative were high.
With technical assistance from CHCS and IHI, sponsors planned that firms would
design, implement, and complete targeted interventions for their minority
populations by the end of the Collaborative's two-year operational period.
Sponsors hoped to be able to point to improvement in health outcomes, such as
better diabetes indicators, to demonstrate the Collaborative's success.
As the Collaborative got off the ground, however, it became
clear that the original expectations were not realistic. One sponsor noted, "I
think we were just incredibly ambitious and off target for a lot of it." The
majority of firms did not have critical information on their members—such as
race, ethnicity, and language preference—and without it, firms would find it
difficult to develop targeted interventions. Not surprisingly, the firms spent
most of the first part of the Collaborative working with RAND on data
collection activities, including geocoding and surname analysis (discussion
in Chapter III).
Although the Collaborative discussed interventions earlier in
Phase I, it wasn't until the last six months that most firms shifted their
focus to developing interventions specifically related to their Collaborative
efforts. According to an individual from one support organization, "I thought
they would be further along on the interventions than they were. A lot of this
is because of turnover or because of the time needed for data collection."
Another support organization echoed the frustration, "It's disappointing to me
that we couldn't get more folks to the intervention stage, but that was just
unrealistic given time and measurement issues." In addition, by the time firms
were ready to develop their pilot interventions, they had not yet built strong
relationships with staff from CHCS and IHI. Probably for these and such other
reasons as the firms' interest in keeping their internal processes
confidential, they developed interventions with staff from their own
organizations, often leveraging their own programs and/or activities rather
than looking to support organizations for assistance.
Over the course of the Collaborative, the definition of an
acceptable "intervention" broadened from a narrow pilot program to a wide range
of firm activities, including cultural competency training, data collection,
and long-term goals. The sponsors' definitions of "success" expanded as well.
Over a year into the Collaborative, one sponsor noted, "Whether or not they moved
the needle is less important than did they do something, did it work, and why
or why not."
The analysis focuses on the primary intervention
self-identified by the firms during our round three interviews. Seven of the
nine firms had either completed or were in the process of completing their
primary pilot interventions at that time; two firms were still in the
development stage. We exclude from this analysis initiatives related to
gaining broad support for firms pursuing disparities work or data collection
activities related to the Collaborative, as these activities are the focus of
other sections of this report. At this point, however, in some firms, these
activities were at least as important as the interventions they piloted through
the Collaborative.
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C. Implementation Experience
1. Target Population
Consistent with the agreed-upon focus of the Collaborative,
all firms targeted their primary pilot intervention to members of racial/ethnic
minorities with diabetes (Table V.1). The majority of the firms focused on
subsets of their Hispanic membership; fewer targeted African Americans or other
minority populations. Most firms started small before scaling up to the region
or firm level.
The exact size of the populations targeted, however, varied
significantly from firm to firm and over time. One firm, for example, targeted
diabetic Hispanic members in one of their care centers; while it originally
expected to reach out to 200+ patients who would be encouraged to pursue a
three-drug lipid-lowering regimen, the firm discussed the fact that physicians
had contacted many of these patients, some of whom already were following the
regimen. As a result, the firm reached out only to the 52 patients who were
not known to be on the regimen or to have been contacted. Another firm
targeted 150 to 200 Spanish-speaking members in their diabetes disease
management program. A third firm, lacking information on patients' race,
reached out via a call campaign to all their known diabetic patients (around
25,000), letting them know that certain ethnic/minority groups in particular
might be at risk for diabetes and asking them to respond if they wanted more
information. About 5,000 members responded, giving the firm the opportunity to
follow up.
Some firms used the results of their geocoding/surname
analyses to identify their target population. One firm, for example, whose
intervention had not yet become operational, planned to use geocoding results
to identify "clusters" of Hispanic members with diabetics not receiving HbA1c
testing and/or lipid testing. Other firms focused their interventions in
sections of their service areas generally known to have a diverse racial/ethnic
composition (e.g., Miami, Florida, which is known to have large Hispanic and
African American populations). At least one firm
combined these strategies. First, it implemented its pilot at a center
composed of 90 percent Latino patients. After expanding the pilot to the
region, however, the firm planned to use both surname analysis and GIS programs
to identify the Latino population.
2. Intervention Strategies
Most large, national firms used a provider-based strategy as
their primary intervention/activity for the Collaborative. In some cases, the
intervention targeted providers employed by the firm. For example, one large
national firm implemented a cultural competency program through which it aimed
to train all nurse clinicians and physicians who interface with members as part
of its diabetes disease management program. Another large national firm worked
with a vendor to encourage its affiliated physicians to implement a Web-based
patient registry that helped physicians to track patients with chronic diseases
by showing past and needed future steps at upcoming appointments. A third
national firm provided reminders to providers whose patients missed
appointments or were overdue for preventive services.
Regional firms were more likely to use a variety of strategies
and more often combined multiple interventions/activities "to try to move the
needle" on diabetes interventions. For instance, once regional firm combined a
provider- and a member-based intervention. First, it consulted with minority
physicians about strategies for improving diabetes outcomes, thus identifying a
lack of knowledge about diabetes among their patients as a barrier to
controlling the disease (the provider-based intervention). Based on this
information, the firm used an interactive voice recognition call campaign to
reach its diabetic members and convey a culturally sensitive message explaining
that their race/ethnicity could affect their risk for diabetes and urging
members to respond if they were interested in additional information. The firm
then sent information to members who requested it (the member-based
intervention). Another regional firm partnered with Stop and Shop grocery
stores to offer free interpreter services, eye exams, and other services to
diabetic members (a community-based intervention) in combination with a dropped
referral requirement (system redesign) and waived co-payments for diabetic
retinal exams (member-based intervention,).
3. Planned Measures of Intervention Success
To date, only one of the firms (a large, national firm)
involved in the Collaborative explicitly planned to judge the success of its
intervention on improved outcomes of its targeted population, such as
improved HbA1c test results (Table V.2). According to our round three
interviews, the majority of the remaining firms, including all of the regional
firms, defined (or planned to define) their success as improvements in process measures, such as HbA1c testing and LDL screening rates. One regional firm
noted, "That [analyzing outcome data] would be so complicated it's not even on
the radar screen right now."
While not explicitly assessing success in terms of outcome
measures, one national firm reported that it modeled its pilot on studies that
showed improved outcomes in their intervention populations. Thus, while
not specifically examining outcome measures in its pilot program for the
Collaborative, the firm assumed that improving the process measures would also
improve outcomes.
Findings and Status. The majority of firms are in the
process of measuring and/or analyzing their results. One large national firm,
for example, did not find statistically significant differences in screening
rates between intervention and comparison groups, but they did find outcomes of
the treatment group to be slightly better than the comparison group.
Preliminary data for one regional firm, on the other hand, show that areas participating
in the intervention had improved screening/testing rates over those in the
non-participating regions. Several firms recognized that while most may not
actually reduce disparities under the short timeframe of the National Health
Plan Collaborative, firms developed the capacity to reduce disparities. "We've
built a framework that we can now expand upon to identify and address
disparities. It's foundation work that wouldn't have happened without the
Collaborative. We have a way of identifying people for interventions to reduce
disparities."
Future Work. While it is too early for most firms to
determine the success of their interventions, most firms made plans to continue
and/or expand their pilot activities/interventions to additional members, regions,
and/or disease conditions. One national firm, for example, planned to expand
its pilot intervention from the initially targeted 52 members to an entire
region of the firm with approximately 475,000 patients, half of which are
Latino. Similarly, one regional firm expanded its pilot activities from
Spanish-speaking members with diabetes in three counties to all
Spanish-speaking members enrolled in the health plan. Pilot interventions will
continue into Phase II of the Collaborative (Chapter VIII).
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D. Challenges Facing Firms
Firms faced a number of challenges in implementing pilot
interventions to reduce disparities among their member populations. First,
firms lacked an evidence-based on how to develop interventions. One firm
noted, "Literature wasn't there on interventions." Another firm said that
"where to begin, how to target disparities, and what interventions to
implement" was a challenge. Also according to the firm's spokesperson, "I'm
still wrestling with... what's the big lever to close the gap? This is not
clear to me going forward.... Right now, I'm flying blind, and just
selecting interventions and approaches on face validity."
Firms also cited a lack of data as an impediment to developing
interventions. "Until we have concrete information on our members, it's
awfully hard to create interventions that are directed in the right way."
Similarly, obtaining resources to implement interventions proved challenging
for many. One regional firm noted, "Getting resources for work we want to do
is hard."
Firm structure was also cited as a challenge. Making any
changes in large national firms is difficult. But the regional structure of
national firms made it doubly difficult for them to focus on change at a
macro-level because the regions have significant authority over care delivery
and decisionmaking. Even at small firms, it is difficult to make changes when
they put corporate-level decisions into play. For instance, it took one
regional firm almost one year to implement a "no referral necessary" policy
change for diabetic retinal exams.
In addition, firms cited logistical issues as challenges to
implementation. "Bringing all of those resources together—making sure everyone
was trained and making sure everyone knew what to do—was a Herculean effort."
One firm, for example, had trouble recruiting physicians to participate in
their provider-based intervention. Even after recruiting them, the firm was
faced with the issue of familiarizing and training the physicians on the
Web-based system used for the intervention. "It takes a lot of education to
get the doctors used to the system." Another firm could not integrate data
from its pilot intervention into the rest of its quality improvement data
system.
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E. Intervention Role and Importance at Firms
Many firms view their
activities/interventions to reduce disparities as part of their quality
improvement efforts, rather than as a separate activity (discussion in
Chapter III). "Disparities are just another way to look at quality." This
view is useful in terms of funding and otherwise sustaining disparities
initiatives. One firm noted that the link between quality improvement and
disparities work helped it in the way of funding because there was no budget
specific to disparities projects. That is, "we definitely see disparities work
as relating to quality improvement—it's the main argument we're using for
resources." Also, another firm recognized this important link for the future
sustainability of these activities. "Future sustainability means
institutionalizing disparities work into quality improvement work, so it's just
something that happens."
While most firms recognized the
potential value of their activity/intervention if it was successful, the
specific activity/interventions at this point are often one of many of the
firms' quality improvement efforts and are not seen as a main priority. One
firm noted, "Reducing disparities is ranked well below survival." It's
possible that this viewpoint is the byproduct of competition from outside
forces. For example, one firm is tied up with integrating its new IT platform,
and another has been focused on a recent merger. Despite these "distractions,"
however, many firms claim that their pilots would persist even if the
Collaborative ended. One large national firm noted, "In many cases, the pilots
would continue." Regional firms agree, "The Collaborative started the original
interest in these areas, but I think it would be self-sustaining at this
point."
Many firms are trying to use
the interventions to build a business case for disparities interventions. One
large national firm claims that initiatives have already shown a return on
investment, and several other firms are approaching their disparities work with
this in mind. One firm is attempting to conduct an analysis to support a
business case for disparities, "To the extent that we can say, because we now
have more folks managing their diabetes, and we know what it costs to treat
diabetes when it's not managed.... Purely from the financial standpoint, we
can say that we can save money." Overall, firms said that developing the
business case for disparities work is a priority as they move forward. This
issue will be a major focus of Phase II activities (Chapter VIII).
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