The American Journal of Managed Care September 2004 - Special Issue
Cultural Competency as It Intersects With Racial/Ethnic, Linguistic, and Class Disparities in Managed Healthcare Organizations
Culture in and of itself is not the most central variable in the patient-provider encounter. The effect of culture is most pronounced when it intersects with low education, low literacy skills, limited proficiency in English, culture-specific values regarding the authority of the physician, and poor assertiveness skills. These dimensions require attention in Medicaid managed care settings. However, the promise of better-coordinated and higher quality care for low-income and working-poor racial/ethnic populationsâ€” at a lower cost to governmentâ€”has yet to be fully realized. This paper identifies strategies to reduce disparities in access to healthcare that call for partnerships across government agencies and between federal and state governments, provider institutions, and community organizations. Lessons learned from successful precedents must drive the development of new programs in Medicaid managed care organizations (MCOs) to reduce disparities. Collection of population-based data and analyses by race, ethnicity, education level, and patient's primary language are critical steps for MCOs to better understand their patients' healthcare status and improve their care. Research and experience have shown that by acknowledging the unique healthcare conditions of lowincome racial and ethnic minority populations and by recruiting and hiring primary care providers who have a commitment to treat underserved populations, costs are reduced and patients are more satisfied with the quality of care.
(Am J Manag Care. 2004;10:SP37-SP44)
Minority populations–Hispanics, African Americans, Asian Americans, and other people of color–currently comprise 28% of the population of the United States, and this figure is projected to increase to 40% by 2030.1 Racial and ethnic minorities, especially those with low incomes and limited English proficiency (LEP), experience multiple barriers to healthcare, encounter lower access to and availability of healthcare, and experience less favorable health outcomes.2-9 Multiple barriers to healthcare access exist –such as language, economics, geography, and cultural familiarity–even when minorities are insured at the same level as nonminorities.10,11 The emerging awareness in the United States over the past 3 decades of what is termed "disparity" has presented innumerable challenges, partly because of the lack of scholarship that examines the intersections of socioeconomic, racial, and ethnic statuses. Questions remain regarding how to improve access and quality of care for economically disadvantaged and culturally distinct groups.
This paper examines the definitions of cultural competence within the context of access to care and identifies Medicaid managed care experiences in select states to describe the experiences of underrepresented low-income racial/ethnic minorities within managed care systems. Building on extant empirical literature, we propose strategies to enhance competent and high-quality care for racial and ethnic groups in managed care systems. A computerized literature search was conducted for the years 1999-2003 using the following keywords: Medicaid managed care, disparities; access to services; health services accessibility; access to primary and preventive care, co-payments; cost sharing; low-income, minority, Latino/Hispanic, African American/Black; quality of care, and Medicaid managed care policy. The databases searched included MEDLINE, Social Science Citation Index, and Science Citation Index. In addition, government and Kaiser and Commonwealth Foundation reports were reviewed. A version of this paper was presented at the Conference on Diversity and Communication in Health Care: Addressing Race/Ethnicity, Language, and Social Class in Health Care Disparities convened in February 2000 by the Office of Minority Health of the US Department of Health and Human Services in Washington, DC.
Cultural Competence: Past and Emerging Definitions
In the past, cultural competence has been called cultural sensitivity, cultural responsiveness, or cultural appropriateness; the name "cultural competence" is recent.12 Cultural competence is defined as a "set of congruent behaviors, attitudes, and policies that come together in a system, agency or profession that enables that system, agency or profession to work effectively in cross-cultural situations."2,13 Cultural competence, as originally conceived, emerged as an issue because of public health efforts to make healthcare services more responsive to underserved populations in both rural and urban areas. As the number of patients of diverse racial, ethnic, cultural, and linguistic backgrounds increased in the United States, the need to produce culturally competent providers who incorporate patients' world view into management decisions also grew.
The release of the national standards for culturally and linguistically appropriate services in 2001 drew attention to the need for culturally and linguistically competent healthcare services for diverse populations and attracted the attention of policymakers, medical schools, public health systems, and healthcare providers.12,14 The Institute of Medicine's report Unequal Treatment concluded that ethnic and racial gaps in care beyond access-related factors were attributable to a range of patient-level factors (patient preference, treatment refusal, clinical appropriateness of care), provider-level factors (bias, stereotyping, uncertainty), and system-level factors (lack of interpreters, geography, managed care system).15
Health disparities are associated with factors such as patients' perceived discrimination16 and mistrust of the healthcare system,17 poor or ineffective communication between patient and physician,18 and healthcare providers' lack of cultural competence and sensitivity.19,20 Other contributing factors to healthcare disparities are social factors such as socioeconomic status and racism, and systemic factors such as access to care and communication barriers.21-23 To ensure quality healthcare and access for minority populations, care must be congruent with patients' cultural, linguistic, and literacy needs. A recent study of a large staff-model HMO found that interpreter services can increase delivery of healthcare to non—English-speaking patients by facilitating patient-physician understanding, which affects patient adherence and accuracy of diagnosis and treatment, while fostering trust and increased satisfaction with care.24 Quality healthcare is culturally competent and patient centered.25 Culturally competent care can improve the continuity of a patient's care and health outcomes by increasing the understanding between patients and providers.18,26,27
When healthcare providers and organizations understand and effectively respond to the diverse cultural and linguistic needs of patients, the benefits of a true patient-clinician relationship are more fully realized.28 Several attributes of culturally competent care are useful in examining its meaning within managed care settings:
When culture-specific health beliefs and health behaviors, gender, race, ethnicity, age, and low socioeconomic status are part of a shared dialog between provider and patient, both communication and delivery of care are more effective.29
Providers who are aware of and address potential communication difficulties, and who provide linguistically appropriate and literacy-appropriate information in the patient's native language, interact more effectively with patients.30
Culturally competent providers consider the patient's needs and preferences within the context of his or her cultural beliefs and practices, and understand the importance of these factors in the treatment plan.25
Culture in and of itself is not the most central variable in the patient-provider encounter. The effect of culture is most pronounced when it intersects with low education, low literacy skills, LEP, culture-specific values regarding the authority of the physician, and poor assertiveness skills. It is precisely this intersection that has been poorly understood or ignored. Yet these dimensions require attention in Medicaid managed care settings.
Expanding the definition of cultural competency has implications for underrepresented minority groups. The ability to take into account individual and institutional factors, the known health consequences of poverty, and barriers to healthcare access could lead to new mechanisms and interventions to address health disparities. Healthcare access, health outcomes, and patient satisfaction could be improved, and long-term costs for managed care organizations (MCOs) could be reduced.
Emergence of Managed Care as a Policy Solution to Improve Access and Reduce Costs for Medicaid Programs
The trend toward managed care began in the late 1980s, when the cost of healthcare services escalated at an alarming rate, as evidenced by Medicaid costs, which were increasing by an average of 30% annually during that period.31 Simultaneously, the number of uninsured in the population continued to increase and presented a challenge to those concerned with providing access to healthcare services for the poor and working poor. As a result, commitments to legislate major changes in healthcare that would address the issues of cost and access to healthcare services became part of the national health agenda. Yet the failure of the healthcare reform plan and all competing proposals introduced during the 103rd Congress suggests that the primary focus of this national debate was predominantly to control the cost of healthcare and to support managed care as a viable solution.32 Managed care advocates promoted the notion that a well-run managed care system could provide quality healthcare while at the same time reducing costs.33,34
In an effort to control rising healthcare costs and limit the utilization of services, public purchasers are increasingly relying on managed care models. By the year 2000, almost all states had begun to offer the option of managed care to their Medicaid beneficiaries, with varying degrees of success. Remaining states continue to study plans to transition and restructure state and county systems to managed care.35 Managed care has continued to expand as states experience pressure to contain costs and is increasing in both Medicaid and State Children's Health Insurance Program (SCHIP) programs. The number of Medicaid clients enrolled nationwide in managed care has increased dramatically, with a 3% enrollment in 1983, a 23% enrollment in 1994, and a 58% enrollment as of December 31, 2001.36
Managed care, which is based on the premise that regular use of primary and preventive care can prevent illness and reduce costs, holds great promise for delivering quality and cost-efficient healthcare to low-income families, many of whom face overwhelming barriers to care. But while more Medicaid recipients and low-income children are enrolling in managed care plans, the promise of better coordinated and higher quality care for low-income and working-poor racial/ethnic populations–at a lower cost to government–has yet to be fully realized.37
Medicaid beneficiaries are more likely to have poor health status and therefore incur higher costs for healthcare services.38 Further, a large majority of Medicaid patients lack transportation, live in medically underserved communities, are less likely to have continuous telephone service, and tend to use the emergency room as a regular source of care. In 30% of Aid to Families and Dependent Children households, at least 1 family member reported having a disability.5 More than 50% of Medicaid beneficiaries belong to racial/ethnic minorities.39 In general, underrepresented racial/ethnic minority groups are poorer, have more chronic health conditions (eg, asthma, diabetes, heart disease), engage in more high-risk behavior, and have less access to providers. As a result, they are more expensive to care for. However, unfavorable health status is associated with poverty and limited access to quality health services, not with minority status. The performance of managed care systems in providing care for publicly insured populations in different states must be examined as part of any effort to reduce ethnic and racial disparities in healthcare.
State Experiences With Low-income and Medicaid Recipients: Issues and Challenges