The American Journal of Managed Care September 2004 - Special Issue
Healthcare Disparities and Models for Change
With Healthy People 2010 making the goal of eliminating health disparities a national priority, policymakers, researchers, medical centers, managed care organizations (MCOs), and advocacy organizations have been called on to move beyond the historic documentation of health disparities and proceed with an agenda to translate policy recommendations into practice. Working models that have successfully reduced health disparities in managed care settings were presented at the National Managed Health Care Congress Inaugural Forum on Reducing Racial and Ethnic Disparities in Health Care on March 10-11, 2003, in Washington, DC. These models are being used by federal, state, and municipal governments, as well as private, commercial, and Medicaid MCOs. Successful models and programs at all levels reduce health disparities by forming partnerships based on common goals to provide care, to educate, and to rebuild healthcare systems. Municipal models work in collaboration with state and federal agencies to integrate patient care with technology. Several basic elements of MCOs help to reduce disparities through emphasis on preventive care, community and member health education, case management and disease management tracking, centralized data collection, and use of sophisticated technology to analyze data and coordinate services. At the community level, there are leveraged funds from the Health Resources and Services Administration's Bureau of Primary Health Care. Well-designed models provide seamless monitoring of patient care and outcomes by integrating human and information system resources.
(Am J Manag Care. 2004;10:SP5-SP11)
With the launch of Healthy People 2010, the goal of eliminating health disparities has been placed on the national disease prevention and health promotion agenda.1 Although there is no consensus regarding what a health disparity is,2 healthcare and policy leaders agree that the healthcare sector plays an important role in the elimination of these disparities. Racial and ethnic minorities experience multiple barriers to accessing healthcare, including not having health insurance, not having a usual source of care, location of providers, lack of transportation, lack of child care, and other factors. A growing body of evidence shows that racial and ethnic disparities in health outcomes, healthcare access, and quality of care exist even when insurance, income, and other access-related factors are controlled.3-7 In 2002, the Institute of Medicine concluded that the sources of these disparities are complex and that a comprehensive multilevel strategy is needed to eliminate these disparities. In its 2003 National Healthcare Disparities Report, the Agency for Healthcare Research and Quality concluded that inequality in healthcare persists, disparities have a personal and a societal price, differential access may lead to disparities in quality, opportunities to provide preventive care frequently are missed, little is known about why disparities exist, and improvement is possible, although data limitations hinder targeted improvement efforts.8 Policymakers, researchers, medical centers, managed care organizations (MCOs), and advocacy organizations have been called on to move beyond the historic documentation of health disparities and proceed with an agenda to translate policy recommendations into practice and to disseminate and replicate succesful models more broadly.9
An active participant identified in this agenda is managed care. To highlight and disseminate information about effective local, regional, and national models to reduce health disparities and to bring together experts to compare experiences, the National Managed Health Care Congress convened the Inaugural Forum on Reducing Racial and Ethnic Disparities in Health Care on March 10-11, 2003, in Washington, DC. The invited audience included managed care physicians, nurses and nurse practitioners, pharmacy directors, social workers, case managers, disease management program managers, and compliance staff. Representatives from health plans, MCOs, research organizations, private foundations, and federal and state government shared models, case studies, best practices, and guidelines they have developed.
In this article, we describe working models presented at the conference that have successfully reduced health disparities in managed care. Included are examples from federal, state, and municipal governments, as well as from private, commercial, and Medicaid MCOs.
GOVERNMENT LEGISLATION, REGULATIONS,AND GUIDELINES
In addition to being the largest purchasers of healthcare in the United States, federal and state governments have laws, regulations, and guidelines that govern how healthcare is provided. For example, under Title VI of the 1964 Civil Rights Act, all institutions receiving federal assistance from the US Department of Health and Human Services are prohibited from conducting any of their programs, activities, and services in a manner that subjects any person or class of persons to discrimination on the grounds of race, color, or national origin.10 The federal government also has issued regulations and guidelines to ensure that necessary data are available to monitor and enforce existing civil rights legislation. Examples of federal regulations that require the collection and/or reporting of racial/ethnic data include those for Medicaid managed care and the State Children's Health Insurance Program (SCHIP).11,12 The Health Resources and Services Administration provides oversight to "ensure that all federally qualified community and migrant health care centers collect race, ethnicity, and primary language data."7
Congress also encourages private-sector HMOs and health plans to develop quality assurance standards. The Agency for Healthcare Research and Quality and the National Committee for Quality Assurance promote the development of quality assurance tracking systems.7
The New Jersey legislature is addressing the standardization of cultural competency. New Jersey Senate Bill S-144 will require cultural competency training as a condition of physician licensure.13
The Office of Minority Health in the US Department of Health and Human Services has issued national standards for culturally and linguistically appropriate services (CLAS) in healthcare.14 Four CLAS standards based on Title VI of the Civil Rights Act of 1964 apply to services for individuals with limited English proficiency (LEP). These are provision of timely language assistance services at no cost to each patient/consumer with LEP; providing written and verbal notices to patients/consumers in their preferred language; assurance of competent language assistance; access to easily understood patient-related materials; and signage. The remaining standards recommend that patients/consumers receive effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language; that efforts are in place to recruit, retain, and promote a diverse staff; that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery and that there are measures to hold the healthcare organization accountable for neglect in this area, so that CLAS-related activities are regularly monitored; and that data are collected on patient/consumer race, ethnicity, and spoken and written language to maintain a current demographic, cultural, and epidemiologic profile of the community so collaborative partnerships can be developed. Healthcare organizations also are encouraged to resolve cross-cultural conflicts or complaints by patients/consumers. The Office of Minority Health suggests that healthcare organizations make their progress and successful innovations known to the public.
REDUCING BARRIERS TO CARE
To accomplish the Healthy People 2010 goal of eliminating health disparities, the current healthcare system, which is fragmented and difficult to navigate, must be changed from "top heavy . . . tertiary care to one that is based in primary and preventive care."15 Vulnerable community members in both rural and urban settings face barriers to healthcare due to financial and geographic constraints that lead to reduced levels of care. These individuals endure administrative barriers such as limits on network choices, long waits for appointments with few minority physicians, and limited culturally appropriate educational and communication services.15
Over the past few years, community providers and other organizations have taken on the challenge of reducing these barriers. Noteworthy among these are the initiatives funded by the Federal Health Resources and Services Administration's Bureau of Primary Health Care (BPHC). Community providers have partnered with BPHC to establish collaborative models that address 1 or more chronic diseases known to affect minorities disproportionately, such as diabetes, asthma, cardiovascular disease, and cancer.15
Most BPHC models start with 1 disease and expand to several over a few years, with effective results.15,16 These community based programs have significantly improved statistics for targeted diseases even when other barriers to care remain, such as poverty, lack of education, lack of insurance or employment.15 This approach supports the conclusion of Donald Berwick, MD, MPP, president, Institute of Healthcare Improvement, that if a community-based chronic disease management program can significantly change the data around 1 chronic disease, it can effectively address other diseases through the same model.15
Bureau of Primary Health Care uses the chronic care model developed by Ed Wagner, MD, MPH, director, and associates at the McColl Institute for Healthcare Innovation, Group Health Cooperative in Seattle, Washington. The model has 3 elements: care, improvement, and learning. The care element has 6 components: support of patient self-management; support for collaborative decision making; upgrade of clinical information systems; redesign of delivery systems; reorganization of healthcare systems to include senior leaders and clinic champions on teams; and development of partnerships that take into consideration community resources and policies. The second element, improvement, supports rapid system change under the guidance of senior leadership partnered with the BPHC. The improvement model requires that teams plan, implement, review, and then integrate the change into the healthcare system (ie, plan, do, study, act). The third element, learning, brings teams together to test specific elements of the improvement model during 12 months of intensive learning sessions.16
State and Municipal Models
To reduce health costs, the Washington State legislature mandated a disease management program for Medicaid fee-for-service disabled, blind, and aged clients who receive supplemental security income and are high users of health services. Clients with asthma, diabetes, and congestive heart failure are targeted. Key components of the model include establishment of a telephone call center; use of field staff nurses to manage high-risk clients through home visits; payments for interpreter and translation services; and a strong information system that links staff in the field with central experts and makes appropriate referrals.17
Some public hospital systems have taken the lead in reducing barriers to access. According to Karen Scott Collins, MD, MPH, Senior Assistant Vice President, New York City Health & Hospitals Corporation (HHC), its hospitals are seeing results from several major efforts to improve access by minorities, who constitute the overwhelming majority of patients served.18 First, HHC has enhanced its efforts to certify eligible uninsured clients for Medicaid and other third-party reimbursement. Enrollment staff are now located within ambulatory care clinics to assist clients in filling out applications and securing coverage.
Two major HHC quality-improvement goals have also shown results: the first is to accommodate any outpatient for a visit within 3 days of the initial call, and the second is to streamline the visit and waiting time so that a client can complete a visit in 45 minutes. Several hospitals are now close to these goals, and the no-show rate of clients has dropped from 40% to 20% for hospitals furthest along in improving access.18 Additional HHC initiatives include reducing language barriers and hiring patient navigators to help move patients within a healthcare center.
Managed Care Organization Models