Collection of Data on Race/Ethnicity and Language Proficiency of Providers
Published Online: December 20, 2013
David R. Nerenz, PhD; Rita Carreón, BS; and German Veselovskiy, MS
Since 1998, a variety of public and private policy initiatives have encouraged health insurance plans to collect data on the race and ethnicity of their members,1 and health plans have also been either encouraged or required to collect data on language needs of members who are not proficient in English.2 The data are used to identify disparities in care, identify targets for quality improvement initiatives, and set priorities for translation and interpretation services. The overall goal is to ensure that access to care and quality of care do not vary as a function of race, ethnicity, or primary language, and to improve healthcare quality for all plan members.
In a closely related set of policy and health plan initiatives, data on the race, ethnicity, and language proficiency of network physicians have also been collected.3 It is presumed, with some empirical justification,4 that physicians who share significant elements of background and culture with patients will find it easier to communicate essential healthcare messages, to better understand patients’ feelings and experiences, and possibly to provide better quality care.5,6
Health plans that have information on the race, ethnicity, and language proficiency of providers can use this information to provide members with the opportunity to voluntarily select providers through a variety of specific mechanisms. Plans can use the information as a foundation for initiatives to increase the racial, ethnic, and linguistic diversity of physicians for inclusion in their provider networks so that there can be network physicians available for members who have linguistic needs or cultural preferences. More specifically, provider information available to members at the time of plan enrollment can include information on race, ethnicity, and language to enable members desiring a physician who can understand their cultural beliefs and language needs to make a selection using information provided by the plan.
Collection of data from physicians or other providers about race, ethnicity, and language poses some unique challenges to health plans. Some providers may be reluctant to provide such data out of concern that patients may actually select against, rather than for, a specific characteristic.7 Providers may also fear that plans might use the information to exclude, rather than include, them in network contracts.8 Providers with moderate fluency in a non-English language may indicate that they speak that language, but actually do not have sufficient proficiency to carry out complex medical discussions with patients.9 Some providers,like some patients or plan members, may not accept or understand the specific race/ethnicity categories and may find it difficult to answer such questions, even if otherwise willing.10 For all these reasons, health plans’ collection of data on the race, ethnicity, and language fluency of providers has been more complex and more challenging than collection of data on the race, ethnicity, and language needs of members.11
The Patient Protection and Affordable Care Act (ACA) of 2010 created an additional element of context for the collection of race, ethnicity, and language data on providers, as it included a requirement that health plans certified for participation in federal and state insurance exchanges include “essential community providers” in order to serve low-income or medically underserved individuals (Section 1311). Although the legislation and associated regulations did not specify race, ethnicity, and language competence as defining characteristics of essential community providers, the law encourages health plans to improve healthcare access for a population of patients who generally access care in medically underserved areas.
Since 2003, America’s Health Insurance Plans Foundation (AHIPF), with funding support from the Robert Wood Johnson Foundation (RWJF), has conducted periodic national surveys of health plans’ collection and use of race, ethnicity, and language data.12 The early surveys in the series focused on collection of data on race, ethnicity, and language preferences of members, but surveys since 2006 have included questions on collection of such data from network providers. In this article, we summarize findings from the 2010 AHIPF-RWJF survey on health plans’ collection of race, ethnicity, and language data from providers and compare responses from 2010 with those of earlier surveys that also included questions designed to collect race, ethnicity, and language data from network providers and health plan staff.
The sampling frame for the 2010 survey was developed using listings in the Atlantic Information Service’s Directory of Health Plans: 2010.13 Leased networks, plans that were no longer in business or had merged, plans with unknown enrollment, and very small plans (enrollment <6500 for commercial, <20,000 for Medicaid, and <5000 for Medicare plans) were excluded, and local/regional subsidiaries of large national companies were collapsed into their respective corporate entities. The final list consisted of 250 plans (both members and nonmembers of America’s Health Insurance Plans [AHIP]), all of which were surveyed. Plans were asked to respond to the survey questions for the product (commercial, Medicare, Medicaid) with the largest enrollment. However, because most health plans had the largest enrollment in a commercial product, 11 multiproduct plans were also asked to respond for 1 additional product, Medicare or Medicaid, so that the distribution of product-specific enrollment in the sample reflected the composition of the industry. Data sampling for previous surveys was described in a previous publication.12
Prior to e-mailing the survey to plans, AHIP utilized multiple internal and external contact lists, information from previous survey responders, and company websites to identify the appropriate plan representative to complete the survey. The AHIP staff also sent invitations to companies in the sample to notify the potential respondents about the upcoming survey and ask to confirm their participation.
The surveys were fielded by e-mailing an Excel-based questionnaire, the same approach that had been used in the 2008 survey. (In 2006, the survey was fielded by e-mailing an invitation to a web-based survey.) The AHIP staff sent several reminders to nonresponding plans. All submissions were checked for accuracy and consistency, and several plans were contacted again and asked to clarify their submissions or provide supplementary information. Of 250 plans, 127 (51%) responded to the 2010 survey, including 59 commercial (48% of eligible plans), 51 Medicaid (59%), and 17 Medicare plans (43%). The responding plans represent a total enrollment of 170 million individuals.
We calculated the proportions of health plans with specific characteristics of interest. The statistical analysis was done by using SPSS 16.0 (SPSS Inc, Chicago, Illinois). We conducted the statistical testing for the difference between binomial proportions by calculating the z scores and the corresponding P values. Because our sample included the large share of the population, the finite population correction was included in the significance testing. Because our sample included a large share of the population (>5% of operating health plans in the United States), the finite population correction factor was included in the siginificance testing. This technique takes into account the actual size of the population from which the sample has drawn.
Race/Ethnicity Data of Providers and Staff
Slightly fewer than half of the survey respondents in 2010 reported collecting data on race or ethnicity on any or all of the physicians or other clinicians in the provider network. The proportion of plans collecting these data did not vary markedly by plan type: 41% of commercial plans, 47% of Medicare plans, and 49% of Medicaid plans (45% overall). When weighted by plan membership size, these proportions rose to 53% in Medicaid plans, 74% in Medicare plans, and 58% in commercial plans, or 58% overall. This increase due to weighting indicates that larger plans were more likely to report collecting these data than smaller plans.
Overall, health plans in 2010 reported having race and ethnicity data on 47.3% of their network providers (unweighted data), or 12.8% when weighted by enrollment. The distinct difference in proportions in the unweighted versus weighted analyses suggests that smaller plans were more successful in obtaining race/ethnicity information on providers than were larger plans. Medicaid health plans were more likely to successfully obtain these data from providers than commercial and Medicare plans (37.7% vs 11.7% and 4.2%, weighted data).
Table 1 summarizes the reasons given by plans reporting the collection of race/ethnicity data on providers for doing that data collection. Assessing diversity of provider network and ensuring member access to “minority physicians” were the 2 reasons most frequently cited. (Plans could indicate more than 1 reason for data collection).
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