Nicole Lurie, MD, MSPH

Health insurance plans serve a critical role in public health emergencies, yet little has been published about their collective emergency preparedness practices and policies. We evaluated, on a national scale, the state of health insurance plans’ emergency preparedness and policies.

We queried members of America’s Health Insurance Plans, the national trade association representing the health insurance industry, about issues related to emergency preparedness issues: infrastructure, adaptability, connectedness, and best practices.

Of 137 health insurance plans queried, 63% responded, representing 190.6 million members and 81% of US plan enrollment. All respondents had emergency plans for business continuity, and most (85%) had infrastructure for emergency teams. Some health plans also have established benchmarks for preparedness (eg, response time). Regarding adaptability, 85% had protocols to extend claim filing time and 71% could temporarily suspend prior medical authorization rules. Regarding connectedness, many plans shared their contingency plans with health officials, but often cited challenges in identifying regulatory agency contacts. Some health insurance plans had specific policies for assisting individuals dependent on durable medical equipment or home healthcare. Many plans (60%) expressed interest in sharing best practices.

Health insurance plans are prioritizing emergency preparedness. We identified 6 policy modifications that health insurance plans could undertake to potentially improve healthcare system preparedness: establishing metrics and benchmarks for emergency preparedness; identifying disaster-specific policy modifications, enhancing stakeholder connectedness, considering digital strategies to enhance communication, improving support and access for special-needs individuals, and developing regular forums for knowledge exchange about emergency preparedness.

Health insurance plans are important stakeholders in the healthcare system and serve a unique role in public health emergencies. Prior systematic evaluations of how health insurance plans prepare and respond to these emergencies have not been reported, so we evaluated the preparedness of these key stakeholders. Responding plans represented 81% of health plan enrollment. We identified 6 modifications that plans could make to enhance healthcare system preparedness:

		Establish metrics and benchmarks for emergency preparedness plans and policies.

		Identify disaster-specific policy modifications.

		Enhance state, local, and federal stakeholder connectedness.

		Consider digital strategies to enhance communication.

		Improve support and access for special-needs individuals.

		Create regular forums for knowledge exchange about emergency preparedness.

Over the past 15 years, Americans have experienced multiple public health emergencies, including devastating natural disasters (eg, hurricanes, tornados, floods), environmental disasters (eg, the Gulf oil spill in 2010), bioterror incidents involving anthrax, the H1N1 pandemic, and mass casualty events that killed or injured scores of individuals.

 Additionally, as of August 2014, the World Health Organization declared the Ebola outbreak to be a public health emergency of international concern.

 The health and healthcare implications of these disasters have been quite varied. They have included the need to seek care in alternate locations due to destruction of communities or healthcare facilities, the loss of medicine or medical equipment, requirements for vaccines or other medical countermeasures, advanced trauma care, and care for the mental health sequelae of the disaster.

 While much has been reported about the preparedness and response of healthcare providers, far less has been published about those of health insurers.

 Public health emergencies can impact health insurance plans in multiple ways because of business disruptions, technology interruptions, or requests from patients and providers to deviate from normal coverage or payment policies so individuals can receive care and, subsequently, communities can recover.

Health insurance plans clearly have an established responsibility in the direct financing of healthcare, yet less attention has been paid to the unique role that health insurance plans fulfill in public health emergencies.

 Notably, the ways in which health insurance plans structure policies for beneficiaries before, during, and after disasters can significantly impact how individuals access and use healthcare services during disruptive events and their aftermath. A surge in demand for medical care during disaster events, for example, can send communities in search of nontraditional healthcare providers or alternate care facilities.

 Maintaining continuity of operations and information about available resources is an important responsibility for health insurance plans. To achieve this, health insurance plans need to be able to rapidly inform beneficiaries of their level of coverage and, in some cases, relax benefit restrictions or create new emergency plans.

The speed at which a health insurance plan can fulfill these critical responsibilities is, in part, contingent upon their disaster-management infrastructure and resources. Following Hurricane Katrina in 2005, America’s Health Insurance Plans (AHIP), the national trade association for the industry, convened its Readiness Task Force to identify strategies that health insurance plans use in disasters. A resulting white paper outlined the definition of a disaster, providing sample disaster plans and best-practice case studies of business models and policies.

However, we are unaware of any systematic examination of how health insurance plans across the nation prepare for or respond to public health emergencies.

As significant emergency events with broad impacts on health are currently in progress (eg, the Ebola epidemic)

 and will inevitably occur on a continuing basis, the study’s aim was to better understand the current state of preparedness of health insurance plans and to identify health insurance industry best practices for public health emergencies.

We surveyed health insurance plans across the United States to learn more about their preparedness and response policies and practices.

We surveyed all health insurance plans that were members of AHIP, a national trade association whose members provide health and supplemental benefits through employer-sponsored coverage, the individual insurance market, and public programs (eg, Medicare and Medicaid) to more than 200 million Americans. We defined health insurance plans as companies providing a risk-based, primary care health insurance product based on a regional provider network.

We developed survey content from a published report of the AHIP Readiness Task Force,

 and input from emergency preparedness experts, representatives of health plans, and officials at various levels of government. The survey (eAppendix A, available at www.ajmc.com) focused on 4 areas

: infrastructure (eg, existing emergency plans, metrics to evaluate these plans), adaptability (eg, events and triggers which might lead to an alteration of services, approaches to tracking and monitoring data, members with special needs), connectedness (eg, communication of plans to members and employees, ability to maintain up-to-date contact lists of partners, participation in collaborative exercises), and best practices/lessons learned.

We used information from the 2012 Directory of Health Plans, published by Atlantic Information Services, to determine each health insurance plan’s size, type of product, and area of operation. We categorized health insurance plans by size as follows: national (5 million or more enrollees), large (1 million to <5 million enrollees), medium (250,000 to <1 million enrollees), and small (<250,000 enrollees).

We pilot-tested the survey with 5 health insurance plans to ensure that the questions appropriately addressed the topic areas and were consistently understood by health insurance plan representatives. We also used the pilot to assess terminology, comprehensiveness, and response options. The primary recommendations from the pilot were minor edits and did not involve the addition or deletion of any questions developed for the survey.

AHIP notified the CEO of each plan about the voluntary survey. The survey was then sent to the person identified at each plan by AHIP as most responsible for business continuity or emergency preparedness (eg, chief medical officer, chief information officer, or chief operating officer). As needed, CEOs were contacted to facilitate survey completion. Follow-up calls were also made to promote engagement and address any questions that health plans may have had regarding the study. We distributed the survey via e-mail, with weekly reminders, from February 28 to May 1, 2013. AHIP also precontacted plans with incomplete or unanswered surveys by phone throughout the study period.

We calculated summary statistics and conducted bivariate analyses for key questions. To evaluate differences in responses by plan size, we used the χ2 test for differences among more than 2 proportions with (the application of) the finite population correction factor and Yates’ correction for continuity, as appropriate (ie, when >20% of cells had <5 count). All analyses were conducted using SAS 9.2 (Cary, North Carolina).

Of the 137 health plan members of AHIP, we received responses from 86 (63%). These 86 plans represent 81% of national private health plan enrollment and provide coverage for 190.6 million members across the United States. The responding plans varied by size, with the highest response rates from national (100%) and large plans (86%) compared with small plans (46%). We describe our major findings in 

All responding health plans had business continuity plans in place. Nearly all plans, regardless of size, reported having plans for business interruptions due to loss of critical infrastructure (eg, emergency power generators) or technical infrastructure (eg, information technology software or communication networks). Although there was variability by health plan size, most plans reported having emergency teams (85%) and emergency personnel (emergency recovery teams, 81%; disaster/emergency manager, 72%). Additionally, 59% reported having physical spaces (eg, emergency operations centers) for managing emergencies, and 40% reported having an emergency call center.

More than half of the health plans (59%) had established preparedness metrics to evaluate their emergency response and planning operations (eg, state of readiness [36%] or percent of operations restored [28%]), but we did not define these further in the study. There were no differences identified with regard to these metrics by health plan size.

Responding health insurance plans provided several concrete ways that they could further enhance their emergency preparedness efforts for both internal operations and member-related activities. These included use of social media outlets for communicating with members, customers, and providers; emergency preparedness webinars; construction of early alerts, checklists, lists of emergency contacts, and situational updates; and exercises for the industry to prevent and counter cyber attacks.

More than 95% of the plans indicated that a federal or state emergency declaration would trigger an internal review of their benefits (policy liberation). Most plans indicated that the changes they would most likely consider during an emergency period would include extending the time period for filing claims, revising or relaxating of out-of-network restrictions, and temporarily suspending business rules for prior medical authorization. Other changes they might consider include suspending business rules for precertification (61%), accepting incomplete claims due to record or data loss (51%), and ensuring the availability of electronic medical records to facilitate continuity of care (40%).

Some respondents reported having specific policies for assisting individuals with certain healthcare needs. Although more common in national plans, more than onethird of health insurance plans overall had capabilities to monitor and assist special populations: those dependent on durable medical equipment (34%), prescription drugs such as insulin or methadone (46%), and home healthcare (35%). Almost all the surveyed health insurance plans reported having the capability to use their claims data to monitor patient care needs, prescription medications, and provider/service utilization.

Although variability by plan size was identified, most health insurance plans indicated that they were able to communicate with stakeholders—such as members, employer groups, and providers&mdash;within 24 hours of a disaster. Prompt communication with public health officials occurred less often, and several plans indicated challenges in knowing who to contact within federal (61%), state (82%), and local (66%) regulatory agencies in the event of a disaster or public health emergency.

The vast majority (82%) of health insurance plans participated in internal preparedness drills. Fewer (30%) participated in preparedness drills with external stakeholders. Most expressed interest in engaging in these activities.

Many health plans shared specific lessons learned and best practices (

). Identified themes include using preparedness planning software, conducting regular emergency preparedness exercises, creating and maintaining spare storage capacity before backing up data, and using text messaging to keep staff informed in the event of emergency. Notably, 60% of health plans expressed interest in participating in a forum to further share and communicate about their specific experiences related to emergency preparedness.

To our knowledge, these data represent the first national view of health insurance plans’ emergency preparedness. Responding health insurance plans represented more than 190 million members, accounting for 81% of total health insurance plan enrollment in the United States. While differences were observed across plans relative to size, many small and medium health insurance plans reported preparedness resources and infrastructure similar to large and national plans.

We identified numerous areas in which health insurance plans have made significant efforts to prepare and respond to emergencies affecting the health and healthcare of their employees and members. We also identified 6 ways that health insurance plans can modify or supplement their existing policies and practices to further the preparedness efforts of the collective healthcare system:

1. Establish metrics for evaluating emergency preparedness plans and policies, and use them for benchmarking.

 Most respondents had basic emergency preparedness tools and policies in place, and 59% reported using specific metrics for evaluating tools and policies. While metrics specifically listed in the survey were not exhaustive, less than half reported using readiness, percent of operations restored, or percent of critical systems tested for benchmarking. While intermittent surveys may provide a snapshot of health insurance plan preparedness, industry-developed metrics could be helpful for real-time and ongoing benchmarking of preparedness. Additional metrics could be adapted from the best practices of other businesses and tailored for the unique challenges that health insurance plans face.

2. Identify policy modifications specific to health insurance plans for disasters.

 More than 80% of health insurance plans indicated they would make policy changes (eg, extending the time period for filing claims or relaxing out-of-network restrictions) in the event of a disaster, while some (40% to 50%) identified other modifications (eg, ensuring availability of electronic medical records to facilitate continuity of care or implementing a process to accept incomplete claims due to record or data loss). A need for specific service modifications has already been identified after prior disasters such as Hurricane Katrina,

when patients with chronic illnesses were transported to offsite locations and needed access to medications. Similar challenges arose after the 2011 catastrophic tornado in Joplin, Missouri, when patients were displaced and needed assistance with medical record access

 and input from health insurance plans about relaxation of restrictions for out-of-network care.

3. Enhance health insurance plan connectedness with state, local, and federal stakeholders. 

While the network of organizations in a healthcare system is vast, it is possible to enhance emergency communications between health insurance plans and other healthcare organizations such as hospitals and health departments. Improvements could be made regarding the specification of contact individuals in various organizations, routine maintenance of contact lists and what information to share with public health officials, and participation in local and national drills. Health plans indicated that while coping with a disaster, they sometimes struggled with finding accurate, up-to-date information about available physical resources (eg, whether a particular hospital clinic or long-term care facility was open) and vaccines (eg, indications for use or availability). Related challenges—such as determining reimbursement policies for care in nontraditional environments or service areas with voluntary evacuations, rather than government-mandated evacuations&mdash;weren’t directly evaluated in this survey, but they have been identified by healthcare providers and healthcare organization leaders in informal post-emergency debriefings and meetings.

Improving healthcare system connectedness (eg, contact lists, drills) and information exchange is consistent with the National Health Security Strategy Implementation Plan (2012) and guidance from the Hospital Preparedness Program. Both promote healthcare coalitions (HCCs) as models for fostering engagement of organizations across various sectors.

 In this context, HCCs bring together healthcare stakeholders for leveraging resources, drills and exercises, engagement, integration across groups, enhancing situational awareness, and other activities. This coordination of healthcare organizations and resources has improved some aspects of response in many events, including the Boston Marathon bombing and Hurricane Sandy.

4. Consider digital strategies to enhance communication.

 In the current information technology age, in which individuals and organizations are increasingly connected through networks and mobile phones, digital-based strategies for data collection and message dissemination could also help the emergency preparedness of healthcare systems and health insurance plans.

 Streamlined, readily available approaches for information surveillance and exchange (eg, websites, telephone hotlines, short message service text) could be very useful in this context.

5. Improve support and access to resources for individuals with special needs.

 Individuals reliant upon electricity-dependent medical equipment and life-sustaining healthcare services are particularly vulnerable in disasters that result in prolonged, widespread power outages since their access to care and other needed resources can be severely disrupted.

 Our survey revealed that most health plans have policies and the capability to use claims and other data systems to help monitor potential care interruptions, access to healthcare services and facilities, and reliance upon life-maintaining medical equipment. Broad adoption of such practices continues to improve health plans’ ability to anticipate community needs during a disaster and to promote emergency planning strategies for particularly vulnerable individuals.

6. Create regular forums for knowledge exchange about emergency preparedness.

 Many of the plans commented on lessons learned from specific events (eg, 9/11, Hurricane Sandy, the H1N1 outbreak), and indicated an interest in participating in forums to further share their experiences. Such venues could help insurers act on many of the study findings and advance the broader preparednessof health insurance plans and the healthcare system, including a focus on emergency plan development and the implementation of such plans across the health insurance community.

Because large plans were more likely than smaller ones to respond to the survey, we cannot readily assess the generalizability of findings across all health plans. However, because responding plans cover such a large percentage of the nation’s insured, the findings from our study do apply to most of the population. In addition, all data are based on self-reporting, so we cannot assess the degree to which the plans, policies, and capabilities could actually be used in an emergency. To date, standardized questions to assess the preparedness of health insurance plans have not been developed, so there may have been relevant content omitted from the survey that could be helpful for describing preparedness. This study represented a snapshot of health insurance plans’ preparedness, while future work could focus on tracking preparedness over time and evaluating the performance and improvement of emergency strategies in subsequent events.

Articles

Health insurance plans serve a critical role in public health emergencies. The authors queried plans about issues related to emergency preparedness: infrastructure, adaptability, connectedness, and best practices.

State of Emergency Preparedness for US Health Insurance Plans

Promoting culturally competent communication at the provider, care institution, health plan, and national levels is likely to contribute to success in reducing racial and ethnic disparities in the receipt of high quality care. Although some health plans recently have shown interest in addressing racial and ethnic disparities in care, very few have addressed how health plans can improve their cultural competency to reduce disparities. This commentary summarizes the importance of culturally competent communication across several levels of the healthcare system and details concrete steps that managed care organizations can take to maximize their ability to provide culturally competent communication and care. 

The importance of effective patient-provider communication in delivering high-quality care is well accepted. Good patient-provider communication is associated with better patient satisfaction, better adherence to treatment recommendations, and improved health outcomes.

 It is assumed, but not proven, that the components of communication that acknowledge and take into account differences between providers and patients–particularly with regard to culture, ethnicity, and beliefs–play an important role in efforts to reduce racial and ethnic disparities in the quality of care. Culturally competent communication refers to communicating with awareness and knowledge of healthcare disparities and understanding that sociocultural factors have important effects on health beliefs and behaviors, as well as having the skills to manage these factors appropriately.

 This issue is so important that the Institute of Medicine, in its seminal report 

, identified cross-cultural training as a key recommendation for reducing healthcare disparities.

 Numerous other organizations have addressed the need to incorporate culture in the training of health professionals.

When applied to healthcare, culturally competent communication is not simply an attribute of the patient-provider encounter. It also is an attribute of the healthcare institution (eg, office, clinic, hospital) and the larger system in which care is financed and delivered (eg, health plan). Promoting culturally competent communication at the provider, care institution, health plan, and national levels is likely to contribute to success. Some health plans recently have shown interest in addressing racial and ethnic disparities in care.

 However, very few have addressed how health plans can improve their cultural competency to reduce disparities.

This Theme Issue aims not only to shed light on the broad array of factors related to racial and ethnic disparities in quality of care, but also to convey the potentially important role that cultural competence and communication play in those disparities. The 6 papers in this issue present information about the role of culture in healthcare communication that health plans and others should find useful, as well as propose mechanisms by which interventions could be developed and evaluated. The issue includes work from 2 important conferences. 

The first meeting was the Conference on Diversity and Communication in Health Care: Addressing Race/Ethnicity, Language, and Social Class in Health Care Disparities, which was held in February 2000. This was the first national gathering of experts in patient-provider communication, cultural competency, health disparities, and health professional training, and was convened as part of a federal response to Schulman et al's 1999 study, which pinpointed the patient-doctor interaction as a potential source of disparity in quality.

 It was sponsored by the Office of Minority Health in the US Department of Health and Human Services, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, The Commonwealth Fund, and the Sergei Zlinkoff Fund for Medical Education and Research. 

Four papers from this conference are included in this issue. Zambrana and her coauthors expressly examine the intersections of race, ethnicity, socioeconomic status, and culture within managed care systems.

 Horner and colleagues describe the results of an expert panel's efforts to identify strategies for improving healthcare providers' cultural competency.

 de Bocanegra and Gany, in a review of the literature, examine the relationship between cross-cultural provider-patient interactions and health outcomes.

 Putsch and Pololi use a broad approach to review both macro-level and microlevel factors contributing to providers' role in healthcare disparities.

The second conference was the Inaugural Forum on Reducing Racial and Ethnic Disparities in Health Care in March 2003, sponsored by the National Managed Health Care Congress and AmeriHealth Mercy, a large Medicaid managed care organization. Baquet and Carter-Pokras review the wide range of strategies that emerged from this conference.

 They present models to reduce healthcare disparities from private, commercial, and Medicaid managed care organizations. 

The sixth paper, by Carter-Pokras and colleagues,

 did not stem from either conference but was included in this issue because of its topical appropriateness. They discuss how use of trained interpreters can overcome problems that providers and patients have in communicating with one another and present interpretation service options. 

Why Culturally Competent Communication Matters

Patients bring to the healthcare encounter cultural backgrounds, beliefs, practices, and languages that require culturally competent communication to maximize the quality of care they receive. For instance, patients and providers may have different understandings of the relationships among illnesses, illness symptoms, etiology, expectations about appropriate treatment, and what is expected of them in the process.

 Also, asking questions of healthcare providers is not an acceptable behavior in some cultures. Patients from these cultures may be less likely to ask even clarifying questions and, subsequently, may not understand their condition or be able to follow their treatment plan, potentially resulting in a lower quality of care or even medical error. Also, many patients utilize traditional remedies and may be reluctant to inform their biomedical providers about them, leading to potentially dangerous interactions between medication prescribed by the 2 types of providers.

When patients and providers speak the same native language, patients are more likely to report positive physical and mental health outcomes.

 Alternatively, patients' inability to communicate in their native language could lead to delays in care, fewer or missed appointments, nonadherence to therapy, and medical error.

 Providers may further complicate the receipt of quality care if they are unable to comprehend the health complaints of patients with limited English proficiency. Absent adequate translation resources, patients' relatives or hospital staff may be asked to translate, although numerous studies have documented problems with this approach, ranging from mistranslation to patient unwillingness to disclose important but sensitive information in the presence of a family member.

 In this issue, de Bocanegra, Carter-Pokras, and their colleagues discuss in greater detail issues surrounding provision of care to persons with limited English proficiency. 

Everyone has a culture, and providers' own cultural backgrounds may affect their communication in the care delivery process if they are unable to recognize or accept differences between themselves and their patients. This may manifest subtly in communication patterns perceived by the patient, or may subconsciously affect clinical decision making. For example, Schulman et al found that physicians had different attitudes toward patient-actors and recommended different treatments for them based on the patients' race and sex.

 Similarly, van Ryn and Burke reported that physicians' beliefs about the likelihood that patients would comply with advice and participate in rehabilitation varied depending on patients' race.

 It should not be surprising that support personnel and providers may hold these negative attitudes. 

Healthcare institutions also have opportunities for culturally competent communication with their patients and the communities they serve. Some institutions strive to make everyone feel welcome and comfortable seeking care; others send subtle messages that some patients are unwelcome. The former message is more likely to be conveyed when an institution's workforce composition reflects the patient population they serve. Another institution-based cultural-competency issue is signage. Inadequate or English-only signage may send a message–intentionally or not–that non-English speakers are unwelcome, potentially contributing to delays in seeking needed care. 

Institutions may make a statement about their cultural competency by not providing sufficient (or any) language translation services. This situation may occur in hospitals located in states that do not reimburse them for translation services, hospitals unfamiliar with the fact that recipients of federal funds are required to provide translation services, or hospitals unaware of their patients' needs.

 This latter issue is rather salient; about 40% of hospitals do not collect data on patients' primary language, according to the American Hospital Association's annual survey.

 Even hospitals collecting such data may not make routine use of these data in care delivery settings. For example, many care settings do not have sufficient numbers of professional interpreters because the data on members' languages were not consulted to assess need. Thus, translation responsibilities often are left to ad hoc interpreters (ie, staff, patients' relatives), who are more likely to commit translation errors having clinical consequences.

Healthcare institutions and health plans share some challenges with respect to culturally competent communication, such as workforce diversity and language-concordant service provision. Similarly, both healthcare institutions and health plans interact with their communities, providing opportunities for culturally competent communication. For example, some hospitals and health plans actively and effectively engage in community-based outreach or health promotion activities in the surrounding communities, or have and value community advisory boards. Also, the degree of outreach reflected in health plans and hospitals' marketing efforts can send important messages. 

Health plans have additional communication-based challenges and opportunities to reduce disparities. One challenge relates to understanding how patients' interpretation of disease and care-seeking behaviors may be conditioned by their cultures. Some ethnic minority members who are reluctant to utilize mainstream medicine may delay seeking care if their health plans do not cover complementary or alternative medical services. Some benefit design and utilization control features may need to account for the diverse needs of members from different cultural backgrounds. For instance, health plans' use of gatekeeping mechanisms to control access to specialty services may inadvertently increase disparities in such care among members from cultures where appealing a decision would not be acceptable. 

Steps to Improving Culturally Competent Communication

How might managed care organizations maximize their ability to provide culturally competent communication and care? Although the evidence base on which to move forward is still being developed, Betancourt, Brach and Fraserirector, and others have identified concrete steps that could be taken, including:

Making cultural competency a core institutional value. Incorporation of cultural knowledge into policy making, infrastructure, and practice is probably one of the most important actions that can be taken because it would guide the conduct of everyday business. 

Providing ongoing training and evaluation on cultural competency issues. This type of training is relatively new, so its effect on patient outcomes and care quality is relatively unexamined.

 However, as noted earlier, improved communication in general is associated with improved outcomes and adherence in clinical settings.

 Aetna is an example of a health plan that has moved in this direction. It now requires its physicians and nurses to complete a cultural competency self-assessment and education program. 

Collecting data on patients' race and ethnicity so quality of care for patients from different racial or ethnic groups can be assessed. Many plans and hospitals have had experience with collecting such data, at least on a limited basis.

 Additionally, plans could consider requiring hospitals and large clinics with which they contract to collect such data and to use these data for quality improvement purposes. In all cases, explaining to patients how these data will be used will be important in moving forward with these efforts. 

Collecting data on patients' primary language. This, too, will help document members' needs and guide service provision. For example, Kaiser's Northern California branch has taken this step by requiring completion of a language field before an appointment can be made. 

Ensuring the provision of professional translation services. This responsibility may need to be shared by health plans and healthcare institutions, depending on their organizational and financial arrangements. Jacobs and colleagues have shown that paying for translator services can be a financially viable solution for health plans once indirect costs (ie, increased utilization of preventive services, potentially reducing long-term costs) are considered.

Involving consumers and community leaders in the design of programs and services to meet the unique needs of racial and ethnic minority patients. 

Contracting with institutions and providers located in racial and ethnic minority communities and helping patients locate providers who speak their language. 

Strategies are in place at the national and state levels to improve providers' cultural competency in healthcare settings. National standards for providing culturally and linguistically appropriate services have been issued by the US Department of Health and Human Services Office of Minority Health.

 Several state Medicaid programs now reimburse for translation services. Some medical schools are beginning to offer training opportunities specifically on cross-cultural issues, although nursing schools have had national standards requiring cultural content in medical training for almost 3 decades. The papers in this issue illustrate the ongoing work in this area and make it clear that opportunities for improving cultural-competent communication exist in actionable ways. 

Nicole Lurie, MD, MSPH

Articles

State of Emergency Preparedness for US Health Insurance Plans

The Role of Culturally Competent Communication in Reducing Ethnic and Racial Healthcare Disparities

Variation in Racial and Ethnic Differences in Consumer Assessments of Health Care

Disenrollment from Medicare HMOs