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The American Journal of Managed Care December 2013
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Collection of Data on Race/Ethnicity and Language Proficiency of Providers
David R. Nerenz, PhD; Rita Carreón, BS; and German Veselovskiy, MS

Collection of Data on Race/Ethnicity and Language Proficiency of Providers

David R. Nerenz, PhD; Rita Carreón, BS; and German Veselovskiy, MS
Health plans collect and use data on network providers' proficiency in languages other than English more commonly than race and ethnicity data on providers.
In spite of the fact that the proportion of plans reporting collection of provider race/ethnicity data was essentially the same in 2006 and 2010, closer examination of the survey data suggested that some plans that had been collecting providers’ race/ethnicity data in 2006 abandoned the practice in subsequent years. There was a statistically significant decline, for example, in the data collection of race/ethnicity of providers for Medicaid plans: 77% collected data in 2006 but only 46% collected data in 2008 (z score = –4.62, P <.001). Table 4 shows the specific pattern of changes in plans’ collection and sharing of race/ethnicity data on providers among a subset of plans that responded both to the 2006 and 2010 surveys (n = 67). Among plans that had been collecting data in 2006, nearly as many stopped by 2010 (n = 15) as continued (n = 20). Perhaps more striking is the observation that, of the 21 plans (shown in first and second columns of Table 4, second row) that were sharing data on provider’s race/ethnicity with plan members in 2006, many more had stopped doing that by 2010 (n = 15) than continued (n = 6). We were not able to determine through this survey why such efforts were suspended.

For those plans that did share information on provider race/ethnicity with members, information on the media used by plans to share that information were available in the 2008  and 2010 surveys. The pattern of media through which plans made this information available to members was similar in the 2 surveys; the most statistically significant change over the 2 years was in providers’ race/ethnicity being more likely to be available through customer services representatives in 2010 than in 2008 (z score = 4.29, P <.01).

Collection of data on languages spoken by providers and staff also showed a modest increase from 2006 to 2010. Increases from 2006 to 2010 were consistent across types of other plan staff. In most subcategories of staff, the percentage of plans reporting collection of language data increased 10%  to 20% across the 4 years. Collection of data on languages spoken for “all health insurance plan staff ” increased by 10% (28% to 38%, z score = 3.00, P <.01) during that period of time (Table 5).

Finally, the percentage of plans that reported testing or verifying language proficiency increased approximately 10% for most major types of plan employees (for example, the percentage of customer service staff tested was 29% in 2008 and 40% in 2010; z score = 2.84, P <.01). The notable exception was the category of providers compared to the network providers’ office staff: 5% each for providers and providers’ office staff in 2008 and only 3% for providers and 5% for providers’ office staff in 2010.

DISCUSSION

Nearly half of responding plans in 2010 reported collecting data on race/ethnicity of providers, but this activity was no more frequent in 2010 than it had been in 2006, and a number of plans that had been collecting race/ethnicity data on providers in 2006 did not continue doing that in 2008 or 2010.

The apparent decrease from 2006 to 2008 (albeit not statistically significant) was somewhat surprising, given that the collection of data on race, ethnicity, and language needs of health plan members has increased steadily for the past 10 or more years.14 Collection of data about providers may be a more sensitive issue. Although the collection and publication of data on provider characteristics would seem to be an essential step to ensuring a diverse and accessible provider network for a diverse health plan membership, concerns about possible exclusions from provider networks or patients choosing against providers of specific backgrounds have raised significant challenges for health plans. Indeed, we found that 15 plans that were collecting data on providers in 2006 were not doing so in 2010. Collecting and providing these data continue to be optional activities for both health plans and providers. Based on personal conversations with health plans that collect these data (Rita Carreón, director, clinical strategies and healthcare equity, America’s Health Insurance Plans, February 8-9, 2012), plans cited limitations in capturing sufficient data on their network providers among other factors such as trust and providers’ concerns related to the use of the data.  Collection of data on languages spoken was more common than collection of data on race/ethnicity, probably because of existing accreditation or purchaser requirements to be able to provide services for patients who have limited English proficiency or who prefer communication in languages other than English, as well as the expressed need by plan members for interaction in languages other than English.15 From 2006 to 2010, health plans expanded their collection of language data on network providers and health plan staff, were more likely to test or verify language proficiency of staff, and were more likely to share this information with plan members.

The study findings clearly have limitations. Although the response rate was reasonable for a survey of this type, we did not have data for the complete universe of operating health plans. It is possible that the nonresponding plans were less engaged in issues related to race, ethnicity, and language data collection, so the activity reported here might overstate the level of activity for health plans in general. One might speculate that health plans serving areas with little racial, ethnic, or linguistic diversity would be less likely to invest in data collection and incorporation of data into programs and member materials; however, qualitative data from follow-up interviews on data collection issues related to plan members’ race/ethnicity did not show such a relatiopnship.16 The sample size of plans did not permit a more detailed analysis of the relationship between service area demographics and activities in the area of race, ethnicity, and language data collection. We also were not able to gather information as to why a subset of health plans stopped the collection and sharing of data on physician’ race and ethnicity between 2006 and 2010.

The National Committee for Quality Assurance’s (NCQA’s) Multicultural Healthcare Distinction Program, which includes aspects of Culturally and Linguistically Appropriate Services, has been in place since 2010.17 Although this program is voluntary and therefore cannot enforce compliance through regular accreditation requirements, the NCQA has clearly sent a signal to plans working with it that collection of race, ethnicity, and language information on plan members, staff, and providers is an important, valued activity. It is not surprising, then, to see more plans reporting activity in this general area in 2010 than in 2008. Specific mention of race/ethnicity and language data collection in the ACA18 and in the second stage of the Health Information Technology for Economic and Clinical Health meaningful use standards for health information technology,19 although not directed explicitly to health plans, has reinforced the message from payers and accrediting bodies that such data collection is expected and essential. Such requirements will presumably encourage physicians and other providers to report this information. In their survey responses about uses of data, health plans indicated that they recognize demographic diversity among their members and are seeking to meet diverse needs. In some cases, the data are used in the design of programs (eg, wellness and disease management) and in the provision of information about benefits and other plan features in languages other than English. In other cases, information about race/ethnicity and languages spoken by providers that is shared with plan members presumably supports choices being made by members about   where to seek care, which will be critical under the new health insurance exchanges that began accepting new enrollment October 1, 2013. The diverse makeup of healthcare providers and clinicians also allows plans to draw on their expertise, via advisory councils, in improving care for racial and ethnic populations and in developing tools and written/verbal messages to consumers. Through this variety of mechanisms, it appears that plans are expanding the ways in which they can provide culturally and linguistically appropriate services to members. 

There is room for continued progress in expanding data collection efforts and increasing the availability of this information to consumers. As our nation’s population continues to become more diverse, the healthcare system will need to meet the increasingly complex cultural and language needs of patients. Although additional research may be needed to further understand the complexities of collecting data on provider networks’ race and ethnicity (eg, the nature of providers’ concerns, attitudes, and beliefs regarding provision of these data), there continues to be general consensus that improving the diversity of the US healthcare workforce is important for health plans and other key stakeholders to help improve access and quality for patients of all racial and ethnic backgrounds.20,21 With public programs now reinforcing the need for such data on practicing physicians and other clinicians through meaningful use requirements, physicians are seeing a concerted message on the importance of reporting such information. A broader discussion within the healthcare stakeholder community on the experiences in collecting and sharing providers’ race, ethnicity, and language data would be a critical step toward increasing patient-provider racial and language concordance.

Author Affiliations: From Henry Ford Health System (DRN), Center for Health Policy and Health Services Research, Detroit, MI; America’s Health Insurance Plans (RC, GV), Washington, DC.

Author Disclosures: Ms Carreón and Mr Veselovskiy report employment with America’s Health Insurance Plans. Dr Nerenz reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RC, DN, GV); acquisition of data (RC, GV); analysis and interpretation of data (RC, DN, GV); drafting of the manuscript (RC, DN, GV); critical revision of the manuscript for important intellectual content (RC, DN, GV); statistical analysis (GV); obtaining funding (RC); administrative, technical, or logistic support (RC); and supervision (RC, DN).

Funding Source: Robert Wood Johnson Foundation to the America’s Health Insurance Plans Foundation (grant #62295).

Address correspondence to: Rita Carreón, BS, Director, Clinical Strategies and Healthcare Equity, America’s Health Insurance Plans, 601 Pennsylvania Ave, NW, Ste 500, South Bldg, Washington, DC 20004. E-mail: rcarreon@ahip.org.
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13. Atlantic Information Services. AIS’s Directory of Health Plans: 2010. 7th ed. Washington, DC: Atlantic Information Services Inc; 2010.

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15. Au M, Taylor EF, Gold M. Improving Access to Language Services in Health Care: A Look at National and State Efforts. Policy Brief. Mathematica Policy Research Inc. http://www.mathematica-mpr.com/publications/PDFs/Health/LanguageServicesbr.pdf. Published April 2009. Accessed April 28, 2013.

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17. National Committee for Quality Assurance. NCQA’s Multicultural Health Care Distinction Program. http://www.ncqa.org/LinkClick .aspx?fileticket=-sEvPOkSGfo%3D&tabid=61. Accessed April 28, 2013.

18. US Department of Health and Human Services. Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. http://aspe.hhs.gov/datacncl/standards/ACA/4302/index.shtml. Published October 2011. Accessed April 28, 2013.

19. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; Electronic Health Record Incentive Program—stage 2; proposed rule. Fed Regist. 2012;77(45):13697-13829.

20. The Sullivan Commission. Missing Persons: Minorities in the Health Professions: a report of the Sullivan Commission on diversity in the healthcare workforce. http://www.aacn.nche.edu/media-relations/sullivanreport.pdf.

21. Smedley BD, Butler AS, Bristow LR, eds. In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: National Academies Press; 2004.
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