In recent years a substantial body of evidence has emerged documenting disparities in health outcomes and in access to healthcare for individuals of different racial, ethnic, and socioeconomic groups. These disparities cannot be explained by variation in clinical conditions. Numerous institutions including the National Institutes of Health, the Institute of Medicine, and the American Medical Association have all expressed concern over these findings. Thus, when the opportunity arose to publish papers stemming from 2 conferences related to health disparities, we were extremely excited. The first conference, held in February of 2000, was the Conference on Diversity and Communication in Health Care: Addressing Race/Ethnicity, Language and Social Class in Health Care Disparities. It was sponsored by the Office of Minority Health in the 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. The second conference, held in March 2003, was the Inaugural Forum on Reducing Racial and Ethnic Disparities in Health Care and was sponsored by the National Managed Health Care Congress and AmeriHealth Mercy, a large Medicaid managed care organization. The impetus to collect and publish these papers came from Olivia Carter-Pokras, PhD, a participant at the conferences and an associate professor in the Department of Epidemiology and Preventive Medicine at the University of Maryland School of Medicine. We thank her for her efforts in bringing this special issue to us.

The papers published from these conferences are a bit different than the types of papers we generally publish. They are not original empirical research studies, but instead reflect the opinions of national experts and the literature in this area. They suggest ways that health disparities may be addressed, and because of this, these papers were evaluated more for their educational merit and their informational contribution to our audience. As such, the Journal is happy to serve as the vehicle to disseminate this information and hope, given the importance of this topic, that our audience finds the papers useful and informative.

Articles

INTRODUCTION

Advocacy and Remedies for Healthcare Disparities

The patientâ€“healthcare provider communication processâ€”particularly the provider's cultural competencyâ€”is increasingly recognized as a key to reducing racial/ethnic disparities in health and healthcare utilization. A working group was formed by the Office of Minority Health, Department of Health and Human Services to identify strategies for improving healthcare providers' cultural competency. This expert panel, one of several working groups called together to explore methods of reducing healthcare disparities, was comprised of individuals from academic medical centers and health professional organizations who were nationally recognized as having expertise in healthcare communication as it relates to diverse populations. During the 2-day conference, the panel identified, from personal experience and knowledge of the literature, key points of intervention and interventions most likely to improve the cross-cultural competency of healthcare providers. Proposed interventions included introduction of cultural competence education before, during, and after clinical training; implementation of certification and accreditation requirements in cross-cultural competence for practicing healthcare providers; use of culturally diverse governing boards for clinical practices; and active promotion of workforce cross-cultural diversity by healthcare organization administrators. For each intervention, methods for implementation were specified. On-going monitoring and evaluation of processes of care using race/ethnicity data were recommended to ensure the programs were functioning. 

Long-standing disparities in healthcare utilization among US minority populations are well documented across a variety of health conditions. Public awareness of this situation was heightened by the recent Institute of Medicine report on unequal access to healthcare.

 The causes of these disparities, and their effects on patients' health status, are now major foci of inquiry. 

Even a casual review of the literature reveals an extensive number of studies that examine the reasons for, and consequences of, observed racial, ethnic, gender, and socioeconomic disparities in the clinical management of many conditions, including cardiovascular and cerebrovascular diseases,

 These studies show that, even within equal-access healthcare systems and the universal healthcare financing programs of Medicare and Medicaid, patients who belong to minority groups are substantially less likely than whites to receive either key diagnostic procedures or effective therapies after adjustment for important clinical indications. Moreover, it is becoming clear that these disparities in the use of diagnostic and therapeutic procedures negatively affect minority patients' health status (see, eg, references 9-11). 

Report of the Secretary's Task Force on Black and Minority Health

There are numerous recommendations for potentially effective interventions; those of the Institute of Medicine report are the most recent.

 In 1985, the Department of Health and Human Services' 

 identified the healthcare provider, patient, and the healthcare system as key points for intervention to correct the disparities in health and healthcare utilization.

 Among its recommendations, the task force called for educational efforts regarding health and disease that are targeted to minority populations, training healthcare providers and educators to be sensitive to minority cultural and language needs, and modifying services to be more culturally acceptable. Also recommended were ongoing monitoring of health data according to patients' demographic and socioeconomic characteristics, and continued research regarding the relationship between patients' cultural diversity and health outcomes. 

Although the patient exercises some control over the outcome of the clinical decision-making process,

 the healthcare provider (eg, the physician) has the primary role in determining the clinical management of a condition.

 A recent study documents that among patients with a similar presentation of cardiac disease, there is significant variation in the physician's decision to refer a patient for cardiac catheterization based on the patient's sex and race. Black women were referred less often for further diagnostic evaluation than white men, black men, or white women.

 Similarly, another report indicates that for procedures involving a higher as opposed to a lower degree of provider discretion (eg, hysterectomy vs acute appendectomy), there is lower utilization among black patients.

 Because interventions directed at healthcare professionals seem more likely to effect change in healthcare utilization and, ultimately, patient outcomes, provider-focused interventions have a higher priority for implementation than interventions targeted at either patients or healthcare systems. 

There is a long-standing need for an action agenda that will systematically move the nation from recommendations to impact. This process involves identifying optimal points of intervention, the potentially most effective interventions at each point, a method for implementation, and a plan for ongoing monitoring and evaluation. This report presents the recommendations from the Working Group on Changing Health Care Professionals' Behavior regarding the most effective approaches to improving healthcare providers' cultural competency so as to reduce disparities in healthcare utilization. 

As part of the larger Conference on Diversity and Communication in Health Care sponsored by the Office of Minority Health, US Department of Health and Human Services, a working group was formed with the charge of developing a set of recommendations for effecting changes in healthcare professionals' behaviors to reduce healthcare disparities in the near term. Other working groups focused on effecting changes in patient behavior and healthcare systems. The working group members were identified by the conference organizers within the Office of Minority Health based on national recognition of expertise in the area of diversity and communication within the healthcare setting. Working group members were drawn from academic institutions and from healthcare professional organizations. 

The major underlying premise of the working group was that observed disparities in healthcare utilization are primarily a function of healthcare professionals' lack of cultural competence. That is, healthcare professionals generally do not understand the health-related and health-system—related beliefs and attitudes of other racial, ethnic, or social class groups, as well as lack awareness of (usually covert or unconscious) biases that they themselves may bring to the processes of patient care. 

The working group began with a brainstorming session from which a broad array of options for modifying providers' cultural competency were generated. Then, the group identified a subset of approaches they believed were most likely to be effective. Subgroups were formed to develop specific recommendations regarding the content and implementation of each approach. 

Mechanisms for Changing Provider Behavior

The group began by considering the currently available mechanisms through which to change healthcare providers' behaviors, whether that behavior relates to cost containment, preferred diagnostic or therapeutic practices, or cultural competence.

 These mechanisms include (1) educational programs, (2) peer review and feedback, (3) administrative changes, (4) active participation, and (5) systems of rewards and penalties. It was recognized, though, that some of these mechanisms may not be either the most appropriate or the most useful approaches to improving healthcare providers' cultural competence. Great creativity may be required to identify administrative changes to increase the cultural competence of healthcare providers, whereas development of educational programs is more straightforward in conceptualization. 

It is now well documented that the more passive forms of education such as consensus statements regarding clinical practice guidelines and didactic lectures (even with follow-up sessions) are generally ineffective,

 although this may be a consequence, in part, of organizational barriers.

 Indeed, organizational characteristics may explain the relative ineffectiveness of low-intensity educational programs; it is reported, for example, that an educational memorandum regarding appropriate use of less expensive histamine H2 blockers with feedback on personal prescribing patterns resulted in a significant change in prescribing patterns among group-based but not network-based HMO physicians.

One intensive educational approach proven to be effective in changing healthcare providers' behaviors is educational outreach.

 Educational outreach or "detailing" is not the typical continuing-education program. It is based on marketing techniques routinely used by pharmaceutical companies.

 Key elements of detailing include the following: 

The interaction between the healthcare provider and the educational agent or facilitator is brief (generally no more than 10 minutes) but highly focused. 

Communication is targeted to the area of practice of highest concern. 

Information is presented in terms relevant to the motivations of the provider. 

Highest priority often is given to providers identified as "opinion leaders" or to providers whose changed behavior would have the greatest impact on practice patterns. (In the case of cultural competence, the high-priority providers would include the most influential providers in a given healthcare facility and those providers shown by actual practice patterns to have the lowest cultural competence. It is worth noting here that a healthcare organization must have an effective mechanism of monitoring practice patterns in order to identify the latter type of providers.) 

The educational agent or facilitator provides a balanced presentation of the issue and involves the provider in the discussion. 

The message is kept simple; that is, only a few points are emphasized. 

There is a feedback mechanism established with reinforcement of the sought-after behavior.

An effective means of educating healthcare providers in training may be to incorporate the principles of detailing into the classroom setting. 

Promising Approaches to Improving Cultural Competency

The working group identified various ways to improve communication between diverse patient groups and healthcare providers, with emphasis given to improving cultural competence among healthcare providers. Although a recent review indicates a lack of empirical evidence on the effectiveness of many of the mechanisms to achieve cultural competency with healthcare systems,

 5 interrelated initiatives were considered to have the greatest potential to improve healthcare providers' cultural competence. These initiatives are described in detail below and in 

. Cultural competence training for healthcare professionals should be a fundamental part of the curriculum and be required for professional certification. It is worth emphasizing that training in cultural competence is not similar to training in other "competencies" (eg, mastery of procedures). It is a complex mix of specific types of knowledge, self-awareness, and their application to the processes of diagnosis, treatment, and clinical decision making.

 The instruction in cultural competence should be continuous throughout the formal training period and during practice. The target audience for cultural competence training includes all healthcare professionals either in training or currently involved in direct patient care (eg, dentists, nurses, physicians, physician assistants, psychologists, social workers). Clinic staff and administrators also may benefit from cross-cultural training programs. The programs could be integrated into clinical care; that is, the training could occur in a clinical setting (eg, during a physical diagnosis). It also must be recognized that cultural competence is an incremental process that is unlikely to be achieved by a 1-time course of study. 

As indicated previously, the concept of cultural competence includes awareness of one's own value system or cultural perspective, understanding of culture and its interaction with health and healthcare, sensitivity to the cultural issues of each patient, and understanding how to address the patient's healthcare needs in a manner congruent with his or her culture.

 One might add to this list of defining characteristics an understanding of one's own (often unconscious) biases toward individuals of different races, ethnic backgrounds, social classes, or language groups. 

The curricular content needs to address knowledge, attitudes, and skills. This content should include but not be limited to: 

Epidemiologic data on race, ethnic, socioeconomic, and other culturally related differences in the incidence and prevalence of disease and disease pathology (eg, location of atherosclerotic lesions).

Fundamental skills in effective communication with diverse populations.

Basic knowledge regarding cultural competence.

Ability to communicate (through interpreters if necessary) with the predominant patient populations served by a given healthcare facility.

Evidence-based cross-cultural training specific to races, ethnicities, and social classes of the provider's practice. Evidence-based information should be provided about normative cultural values, language issues, folk illnesses, patient beliefs about health and sickness,48 and specific cultural practices (eg, infant head molding

), particularly as they relate to the predominant cultural groups served by the given healthcare facility.

The training program should utilize multiple learning methods that are known to be effective, including roleplaying, standardized patients (ie, an actor playing a patient with a specific condition or disease), critical incidents, specific case presentations, and interactive lectures. Trainers for cultural competence programs should include patients, outside consultants such as indigenous healers and culture brokers, and interdisciplinary healthcare professionals. 

There should be ongoing evaluation of the training programs, with particular emphasis on measurement of specific effects. One primary measure is the utilization of diagnostic procedures and treatments within marker diseases or conditions. The target conditions include, but are not be limited to, the high-priority areas of Healthy People 2010, such as cancers, diabetes mellitus, heart disease and stroke, and HIV/AIDS.

 Other candidate marker conditions are those for which racial, ethnic, and socioeconomic differences in the diagnostic or therapeutic processes have been documented (eg, pain management

). Additional measures of the effect of a training program could be patient and healthcare provider satisfaction with the healthcare communication process during appointments. 

Monitoring of Healthcare Processes and Outcomes.

 It is essential to measure progress in elimination of inequities. Each healthcare facility should monitor those health conditions with known disparities in processes of care (ie, diagnosis and treatment), patient satisfaction, and outcome of care related to race, ethnicity, non—English-language status, and patient social class. 

The monitoring program could be part of institutional quality assurance programs. If so, facilities would need to modify their current quality assurance programs to allow for the routine collection and analysis of these types of data, and for the feedback of results to healthcare providers at all levels. Correction of identified disparities would be the responsibility of the facilities. 

Certification and Accreditation Requirements.

 As an additional requirement for professional certification, each healthcare professional could be required to document cultural competence. This process might be most effective if it involved the active participation by the various certification and accreditation organizations: the Joint Commission on Accreditation of Healthcare Organizations, licensing boards, and national, state, and local accrediting boards, including organizations that approve continuing education (eg, Association of American Medical Colleges, American Nurses Association, National Association of Social Workers). Federal and state initiatives and regulations regarding cultural competence among healthcare professionals also could be initiated and enforced. Currently, at the federal level, there is the Healthcare Fairness Act; model legislation at the state level is the proposed New Jersey bill requiring cultural competence training of healthcare professionals. 

Diversity in the Membership of Governing Boards.

 Key stakeholders in healthcare facilities should be involved in changing provider behaviors related to cultural competence. Thus, the oversight or governing boards should include representatives from all groups of healthcare providers, administrators, third-party payers, members of professional societies, patients, interpreters, and other cultural brokers (eg, folk healers). Healthcare facilities involved in international healthcare should include the appropriate international representatives or contacts among the members of their oversight or governing committees. 

The members of the cultural-competence oversight or governing boards would be responsible for monitoring and evaluating healthcare provider behavior as it relates to cultural competence. Among their key tasks would be defining the outcomes to be monitored, setting goals, and assessing whether the goals are being met. The governing boards also could establish media liaisons through which to publicize the progress toward cultural competence among all the staff of community healthcare facilities. 

Enhancing and Retaining Diversity in the Healthcare Workforce.

 Healthcare facilities could seek work place diversity that reflects the demographics of the population being served. It is recognized that a balance will need to be achieved between the need for cross-cultural competence and the other demands of patient care. Balance could be achieved by employing interpreters who meet the needs of the facility and by actively identifying the visits that will require an interpreter's services. Professional healthcare interpreters should be employed whenever possible. In general, clinic staff should not be used routinely as interpreters, but if so used, the staff member should be released from his or her primary responsibilities. Additional time for the visit also should be planned into the schedule when interpreters will be involved. 

One approach to help ensure effective recruitment of minorities at all staffing levels is to develop an adequate "pipeline" for professional training.

 This activity must begin at the earliest levels of education. From kindergarten through high school, programs for mentoring and support of students interested in the health sciences can be effective in increasing the number of minority students who have majors relevant to the healthcare professions at the undergraduate level. Potentially effective ways to increase the number of minority students in health professional schools include education grants or scholarships, loan repayments, guaranteed employment in underserved communities, and other such incentives. Programs designed to facilitate the application process and to support underrepresented applicants are another promising approach. 

To recruit and retain providers, broadly based community partnerships with local healthcare providers, businesses, and educational and service organizations could be developed. Moreover, monetary incentives could be made available to healthcare organizations in communities with large minority populations to encourage the hiring of healthcare professionals to match the diversity of the community. The amount of the incentive could be based on the diversity among the consumers of care in the particular community. That is, facilities located in highly diverse communities would receive a larger monetary incentive than facilities in less racially or ethnically heterogeneous communities. Each facility would be responsible for assessing the diversity of its consumers of care. 

There are a number of other means for supporting a diverse workforce. These include: 

Ensuring continuity of cultural competence by providing the staff with continuing education.

Giving practitioners the resources to be cross-culturally sensitive in practical ways (see Training in Cultural Competence).

Providing incentives to the staff such as textbooks, pamphlets, Internet access, and subscriptions to journals.

Guaranteeing that Title VI regulations are followed in practice (eg, making transportation and interpreters available).

The resources for implementation and coordination of these "wraparound" services should be the responsibility of each facility. 

It is increasingly clear that the healthcare provider plays a pivotal role in the interaction between providers and patients from diverse populations. The experts comprising the Working Group on Changing Healthcare Professionals' Behavior concluded that improved cultural competency among these professionals would yield improved communication with patients from diverse backgrounds, reducing disparities in health and healthcare utilization. A set of 5 approaches were identified as having the highest potential to increase cultural competency among healthcare professionals: cultural competence education before, during, and after clinical training; ongoing monitoring and evaluation of processes of care; certification and accreditation requirements; use of culturally diverse governing boards for healthcare practices; and promotion of workforce diversity. These approaches reflect current understanding and can be implemented now. 

Current knowledge is sufficient to begin the process of reducing diversity-related and language-related disparities in healthcare utilization by improving healthcare provider behaviors. However, in order to continue the process, further attention needs to be directed to several areas. 

First, current knowledge regarding the reasons for the observed disparities in health and healthcare utilization must be refined. Significant gaps in knowledge remain, particularly about the interpersonal processes of care.

 could provide an initial research agenda that would generate studies to extend current understanding of important associations. The elicitation of symptoms and evaluation of signs are highly related to the patient's cultural characteristics.

 The selection, dosage, and monitoring of adverse effects of psychotropic medications need to be done with regard to the patient's culture, as reactions to these medications differ across cultural groups.58 Patients' racial and socioeconomic characteristics clearly have been shown to influence physicians' beliefs about their patients' intelligence, willingness to comply, and likelihood of engaging in risky behaviors, as well as influencing the physician's approach to presenting treatment options (eg, the physician's decision about how much information to provide).

An area of particular concern and urgency is the presence among healthcare providers of covert or unconscious biases toward patients of diverse cultural backgrounds. Research in this area needs to be expanded to include not only physicians but also other healthcare providers. The importance of these types of studies is that they identify specific points of potential cultural conflicts, knowledge that could be useful in developing the content areas for the cultural competence education programs. 

A second area needing further attention is evaluation of the effectiveness of the various interventions that have been suggested. The current status of cultural competence training programs is a case in point.

 A recent survey of the 126 US medical schools found that 8% provided no instruction in cultural issues; in 87%, cultural instruction was part of a larger course and consisted of 1 to 3 lectures; and the course was an elective for 16%.

 Most courses had been taught for less than 6 years, were given only during the initial 2 years of training, used didactic and group-learning formats, and did not specifically address the cultural issues of the largest nonwhite ethnic groups.

 An earlier survey reported that 14% of undergraduate medical education programs in the United States did not have 1 or more educational opportunities relating to multicultural medicine; however, 13% of the programs reported teaching multicultural medicine as a separate course, as opposed to only 8% of medical schools in the more recent survey.

 The content of the existing programs has only begun to be delineated and is highly variable.

The program content of cultural competence training is the subject of a follow-up survey by the Association of American Medical Colleges.

 For the other health professions, we need information regarding the proportion of the professional education programs that have formal training in cultural competence and the content of the cultural competence training programs. 

As a third area for future attention, the cost effectiveness of existing training programs in cultural competence needs to be determined. Neither the costs nor the effectiveness of current or potential programs is known. For example, although it is known that educational outreach can be effective, it is less certain that this approach will be effective in developing the cultural competence of healthcare providers. Moreover, there is a need to identify other cost-effective training programs, as well as to develop global cultural competence. The global effort could include collaborations with international medical institutions and organizations through workshops, symposiums, and summit meetings. The United States and United Kingdom are currently involved in such efforts.

Members of the Working Group on Changing Health Care Professionals' Behavior are Kim Bullock, MD; Karan Cole, ScD (Johns Hopkins Bayview Medical Center, Baltimore, Md); Giselle Corbie-Smith, MD; Martha Cornog, MA, MS; Peter Domoto, DDS (University of Washington School of Dentistry, Seattle, Wash); William Emmet, BA (National Alliance for the Mentally Ill, Arlington, Va); Alicia Fernandez, MD (University of California, San Francisco, Calif); Glenn Flores, MD; H. Jack Geiger, MD, MPH, DSc; Ronnie D. Horner, PhD; Cornelia Porter, PhD (American Nurses Association, Washington, DC, and University of Michigan, Ann Arbor, Mich); William Salazar, MD; and Devi Sengupta, BA, MPhil (University of Washington Medical School, Seattle, Wash). 

SPECIAL ISSUE

Changing Healthcare Professionals' Behaviors to Eliminate Disparities in Healthcare: What Do We Know? How Might We Proceed?

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. 

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.

 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.

 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.

 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.

 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."

 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.

 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).

Health disparities are associated with factors such as patients' perceived discrimination

 poor or ineffective communication between patient and physician,

 and healthcare providers' lack of cultural competence and sensitivity.

 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.

 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.

 Quality healthcare is culturally competent and patient centered.

 Culturally competent care can improve the continuity of a patient's care and health outcomes by increasing the understanding between patients and providers.

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.

 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.

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.

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.

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.

 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.

 Managed care advocates promoted the notion that a well-run managed care system could provide quality healthcare while at the same time reducing costs.

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.

 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.

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.

Medicaid beneficiaries are more likely to have poor health status and therefore incur higher costs for healthcare services.

 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.

 More than 50% of Medicaid beneficiaries belong to racial/ethnic minorities.

 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

States can move toward managed care either by allowing voluntary enrollment or by instituting a mandatory enrollment program. In some cases, the voluntary option comes first and is used as an experimental enrollment strategy, often followed by a more structured and systematic mandatory model. The rapid expansion of Medicaid managed care was seen by the states as a way to improve the quality of care by encouraging more primary healthcare services and less emergency room utilization. In the second generation of managed care, states are moving to ensure quality of care by incorporating innovative approaches designed to guarantee that both psychosocial needs and medical needs are met.

 The states of Oregon and Washington have taken the lead in this regard, as MCOs are mandated to develop a continuum of services that meet the needs of Medicaid populations. Most states, however, are lagging behind and have not developed the capacity to meet the comprehensive needs of low-income and underrepresented racial/ethnic minority populations.

Medicaid managed care experience in 5 states (California, Minnesota, New York, Oregon, and Tennessee) consistently shows that Medicaid managed care confronts more challenges than commercial managed care efforts because the Medicaid population of low-income women and children, the disabled, and the elderly have unique needs that require initiatives to be tailored so that they are responsive to these populations. 41 States vary significantly in their requirements for services such as translation, outreach, and transportation. Oregon, for example, has no such requirement; and Minnesota adopted special services only after it was evident that certain supportive services were an essential and necessary part of providing access for the poor. 

However, in the long term, the stability of Medicaid managed care programs is uncertain. Private HMOs have dropped out of the Medicaid market when the profit margin has declined.

 Although competition for Medicaid business is fierce in most states, the profitability of serving Medicaid clients may diminish if Medicaid officials try to reduce reimbursement rates whenever they conclude that a MCO is making excessive profits. If the federal contribution to Medicaid declines, there will be additional pressure to decrease HMO reimbursement rates. If Medicaid officials introduce program improvements to reduce adverse selection, the profitability of Medicaid clients will diminish even further. 

Addressing disparities in the recruitment and enrollment of Medicaid beneficiaries into managed care plans is critically important for the health of low-income and racial and ethnic populations. In the early wave of recruiting Medicaid clients, many MCOs engaged in recruitment and enrollment tactics that did not protect the rights, options, and choices of the client population. Both Oregon and Minnesota do not allow any direct marketing by health plans, because direct marketing by plans has been associated with abuse of rights in Medicaid managed care. Initially, the New York marketing was conducted from door to door, a practice that has since been suspended. 

There is evidence that some MCOs have engaged in discriminatory practices, including refusing to provide services to entire geographic areas and populations.37,43 The Office of Civil Rights of the US Department of Health and Human Services has been called on to investigate Medicaid managed care enrollment and marketing practices.

 Some MCOs also have been found to engage in additional "skimming" or "creaming" practices such as locating their membership office on the second floor (without access to elevators), or training their enrollment counselors to visually assess whether the enrollee would need a lot of services in order to enroll only the healthiest members.

 States have found that if managed care structures are to benefit all enrollees, the states must establish marketing guidelines and prohibit these discriminatory practices. Populations with low education, low literacy, and/or LEP are particularly vulnerable in the transition to managed care. Notices informing enrollees of their rights often go unread because they are not understood or have not been translated into the appropriate languages of the population. States implementing mandatory enrollment in Medicaid managed care have found that these groups are least likely to respond to enrollment notices and are more likely to be automatically enrolled by the state.

The transition from a fee-for-service system to a managed care system poses a major challenge, with significant implications for the future viability of safety-net providers that deliver healthcare to the poor and near poor.

 Given the high proportion of uninsured persons in the US population (particularly the Latino population), safety-net providers that serve this community are doubly challenged in the managed care environment. Despite the fact that there is no competition among providers to serve uninsured patients, the transition of Medicaid recipients (another patient population traditionally served by safety-net providers) into managed care plans has produced competition for Medicaid enrollees that has implications for safety-net providers.

 The ability of community-based organizations, public hospitals, and public clinics, the traditional safety net for the poor and medically indigent, to compete in the Medicaid managed care environment and to negotiate contracts and appropriate payment rates is uncertain. 

In California, state Medicaid officials have developed a managed care model (the 2-plan model) designed to protect safety-net providers. In contrast, New York State Medicaid officials have neither designed nor implemented a safety-net protection plan. Instead, the state tasked its 57 counties to design and implement their own initiatives to protect the provider safety net.

 Lipson and Naierman argue that this decentralized approach does not provide for clear universal guidelines or clear lines of accountability that would ensure the systematic strengthening and protecting of the safety-net infrastructure.

 The potential lack of long-term MCO commitment to the Medicaid population increases the need to preserve a strong medical safety net to serve the poor and medically indigent.

Safety-net providers have historically been able to cross-subsidize care for the uninsured using Medicaid payments, but as Medicaid dollars decrease while uninsured patients increase, providers are forced to turn to grant money to subsidize their operations. Thus, few to no resources remain for public health programs and health education efforts. But in some communities, the result is even worse: public hospitals, federally qualified health centers, and health clinics are shutting their doors or drastically reducing their services.

 The challenge is not only to contain costs and provide quality healthcare, but more importantly, to secure the future viability of safety-net providers delivering healthcare services to the poor and uninsured. Furthermore, strengthening safety-net providers under managed care may be the 

 way of ensuring that the poor and uninsured populations continue to be served. 

Andrulis argues that the entire tradition of public-sector healthcare is threatened by managed care, as the intensity and growth of the competition might be too powerful for it to withstand.

 He raises 2 central issues: (1) Although community healthcare centers might become attractive to MCOs as a way of gaining entry into certain neighborhoods, it still remains unclear whether MCOs would invest adequate funds to deliver effective healthcare services to low-income and working-poor populations, or whether any autonomous role would remain for community-based organizations under such partnerships. (2) Although in the past a fully vested public sector provided and financed healthcare, the emergence of a "residual public sector" or an entirely "divested public sector" is possible given the current questioning by policymakers and state and local governments regarding what role, if any, the public sector has to play in the new managed care environment.

A review of the nonprofit sector in managed care suggests that to ensure the survivability of the system, innovative models of joint partnership and ownership of managed care enterprises by community providers need to be explored.

 Although the healthcare reform debate addressed the need to better define expectations for the nonprofit sector as a provider of free services, it did not adequately envision the role of the nonprofit-sector providers as entrepreneurs who would assume an ownership role in the system. Unless the nonprofit sector assumes an ownership role in managed care, services for the poor will be compromised.

Community-based organizations providing safety-net healthcare services require particular attention, because they serve a disproportionate number of uninsured. The ability of community-based organizations to compete in the managed care marketplace and gain entry to Medicaid contracts will solidify their position as safety-net providers serving low-income and racial ethnic groups in their community. However, the majority of community-based organizations work within an organizational environment that has few financial and personnel resources available–which makes them less able to compete and negotiate in their environment.

 Community-based organizations that provide healthcare services to the poor and near poor are mandated by their governance not only to provide culturally competent healthcare but also to advocate on behalf of these patients for their rights. The transition to managed care poses additional challenges for these organizations. Organizations adapting to the managed care environment generally lack the technological resources, cash reserves, and sophisticated accounting systems needed to be part of a provider network, despite the fact that they carry the heaviest burden for delivering healthcare services to the poor and underserved.

Managed care organizations can meet their goals of lowered costs and improved access to care by tailoring their services to the needs of the population they serve and by working closely with local community-based providers to increase access, enhance the trust of clients, and utilize existing community resources. Strategies include: 

Provide financial resources to support partnerships between local government, MCOs, and community agencies for outreach and enrollment in publicly funded programs. The involvement of community-based healthcare organizations in improving access to healthcare for low-income, racial/ethnic communities has become increasingly apparent. Many states and counties are beginning to formalize these relationships (particularly in SCHIP programs), and these efforts must be evaluated.

Improve government purchasing. Public purchasers need training on rate setting to establish payment rates that do not discourage MCOs from serving high-risk populations. The costs of providing culturally and linguistically competent healthcare should be included in capitation rate-setting methodologies.

Provide federal subsidies to MCOs that serve low-income vulnerable populations to ensure the provision of supplemental services such as transportation, medical supplies, and medications.

Mandate the inclusion of minority, linguistically competent, and culturally competent providers in managed care networks.

Conduct radio and television mass media education campaigns to help people understand their rights as MCO enrollees.

Primary Care Capacity in Low-income and Racial/Ethnic Communities

Primary care capacity (ie, having enough primary care practitioners to meet people's needs for healthcare) is a critical link to improving the health status of low-income, minority, and LEP populations. People who have access to convenient primary care facilities where care is available in their language receive higher quality care and are less likely to experience serious illness; for those with chronic conditions such as asthma, diabetes, and hypertension, many hospitalizations are avoidable.

Underrepresented racial/ethnic communities have long been plagued with a paucity of medical professionals. In New York City, for example, there are 232 physicians in office-based practice per 100 000 residents. In 9 low-income, primarily minority communities, the rate was as low as 21.6 physicians per 100 000. These communities experienced a severe shortage in primary care capacity within a city that has immense physician resources.

 Racial/ethnic practitioners are more likely to serve minority and poorer patients, and racial/ethnic health researchers are more likely to be interested in problems relevant to minority and historically underserved populations.

 African American physicians are more likely than others to treat patients who are African American and/or on Medicaid; Latino physicians are more likely than others to treat patients who are Latino and/or uninsured.

 Racial/ethnic minority patients also are more likely to feel that their physicians involved them in decisions about their care when the patient and the physician are of the same sex and race.

Over the past several years, the number of African Americans and Latinos admitted to medical school has declined. Although racial and ethnic minority groups represented 19.4% of the US population in the 1990 US Census, they represented only 10.9% of the 1997 medical school matriculants. The shift away from a national acceptance of affirmative action is having a negative effect on the ability to recruit and retain minority students and faculty in the health professions. After Proposition 209 in California and the Hopwood decision in Texas, Louisiana, and Mississippi, applications of minorities to medical schools in these states declined 17% (2.3 times more than the national average), accepted applications of minorities declined 27% (7 times more than the national average), and minority matriculants declined 26% (6 times more than the national average).

At the federal level, repeatedly documented strategies have been recommended to increase the number of underrepresented minorities in the health professions through investments in pipeline programs, mentoring programs, and incentive programs for both providers and MCOs, and more scholarship funds targeting low-income, underrepresented racial and ethnic groups.

 Although federal efforts are required to increase African American and Latino representation in medicine and the health professions, MCOs can enhance the number of primary care physicians and health professionals by recruiting professionals who have a commitment to practicing in underserved areas, by creating opportunities for internships and residencies in MCOs, and by providing financial incentives to underrepresented minority primary care physicians to work in underserved communities. In addition, federal and state governments can strengthen the efforts of MCOs through the following strategies: 

Increase the reimbursement rate for MCOs that serve Medicaid and SCHIP individuals, and provide incentives such as tax credits to encourage MCOs to recruit the participation of more providers in underserved areas.

Create financial incentives for MCOs to reimburse primary care providers who practice in neighborhoods with a primary care shortage at an aboveaverage rate.

Strengthen existing efforts and create new opportunities through the Health Resources and Services Administration to support primary care improvement, especially in MCOs that are located in minority communities (eg, National Health Service Corps, Bureau of Health Professions).

There is no universal understanding among providers and researchers of what culturally competent care is, how to measure or evaluate appropriate care, or how to define successful programs. There are several reasons for this: no established standards define competent care; the costs of providing appropriate care (eg, interpreter services) often are not reimbursed; many public officials, healthcare facilities, and providers are unaware of their obligations or unwilling to provide linguistic and culturally appropriate healthcare to their patients61; and institutional practices often tend to disregard the healthcare needs of those who are unable to pay, have public insurance, or are unable to negotiate the system due to low education and literacy skills, and/or access constraints. In addition, cultural competence involves a dynamic interplay among socioeconomic status, race, ethnicity, and language–an interplay that definitions and interpretations of the term do not always acknowledge. 

Local clinics, health centers, and individual providers have provided leadership in bringing high-quality, culturally competent healthcare to the communities they serve. Yet many publicly financed programs continue to be uninformed about the unique characteristics of the populations they serve. This information gap is associated with provision of less effective services, particularly for those who have a low income and LEP. (See the article by Carter-Pokras et al in this issue for a complete discussion of LEP.

) Several studies have shown that language is important when a person does not have health insurance, has limited education, and has a low income.

 In those instances, qualified medical interpreters– who are aware not only of language appropriateness but also of literacy and culture-specific health beliefs and behaviors–are crucial in bridging the language and culture chasm between patient and physician to effectively communicate health issues.

Training for health professionals on the provision of culturally appropriate care also lacks systematic and comprehensive standards. Schools of medicine, nursing, and public health offer courses on cultural competency. But the quality and depth of these offerings varies dramatically, from a single lecture per semester to an entire course on cultural differences. To date, no clear guidelines or comprehensive standards exist on how to prepare healthcare providers to become culturally competent. When 118 US and 15 Canadian medical schools were surveyed, few schools (United States: 8%, Canada: 0%) had separate courses addressing cultural issues and only 35% of US schools addressed the cultural, economic, and insurance status issues of the largest minority groups in their particular states.

 Managed care organizations can institute continuing education or required training for all healthcare professionals regarding the culture-specific health beliefs and clinical, economic, and language issues experienced by the population they serve. 

To institutionalize a set of practices that ensure equal treatment for all, both federal and state legislative pol

From the Department of Women's Studies and The Consortium for Race, Gender, and Ethnicity, University of Maryland, College Park, Md (REZ); the Community Health Access Department, Community Service Society of New York, NY (CM); Management Sciences Development, Washington, DC (HBM); and the Department of Medicine and the Division of Academic Medicine, Geriatrics and Community Programs, University of Medicine and Dentistryâ€“New Jersey Medical School, Newark, NJ (DSL). 

Prepared for the Conference on Diversity and Communication in Health Care: Addressing Race/Ethnicity, Language, and Social Class in Health Care Disparities; Washington DC; February 17-18, 2000. This study was sponsored by the Office of Minority Health, US Department of Health and Human Services. 

Address correspondence to: Ruth Enid Zambrana, PhD, University of Maryland, 2101 Woods Hall, College Park, MD 20742. E-mail: 

Racial and Ethnic Disparities: Key Findings from the National Survey of America's Families

. New Federalism: National Survey of America's Families Series No. B-5. Washington, DC: The Urban Institute; February 2000. Available at: http://www.urban.org/url.cfm?ID=309308. Accessed July 16, 2004. 

Cultural Competency in Health, Social, and Human Services

2. Lecca PJ, Quervalu I, Nunes JV, Gonzales HF.

. New York, NY: Garland Publishing; 1998. 

3. Lieu TA, Lozano P, Finkelstein JA, et al.

 Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. 

 Uninsured under TennCare: a case study of public health users. 

 Medical care utilization by AFDC recipients under reformed Medicaid. 

 US civil rights policy and access to health care by minority Americans: implications for a changing health care system. 

7. Weech-Maldonado R, Morales LS, Spritzer K, Elliott M, Hays RD.

 Racial and ethnic differences in parents' assessments of pediatric care in Medicaid managed care. 

Cultural Competency as It Intersects With Racial/Ethnic, Linguistic, and Class Disparities in Managed Healthcare Organizations

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.

September 2004 - Special Issue

Advocacy and Remedies for Healthcare Disparities

Changing Healthcare Professionals' Behaviors to Eliminate Disparities in Healthcare: What Do We Know? How Might We Proceed?

Cultural Competency as It Intersects With Racial/Ethnic, Linguistic, and Class Disparities in Managed Healthcare Organizations

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

Healthcare Disparities and Models for Change

Providing Linguistically Appropriate Services to Persons With Limited English Proficiency: A Needs and Resources Investigation

Good Provider, Good Patient: Changing Behaviors to Eliminate Disparities in Healthcare

Distributive Justice in American Healthcare: Institutions, Power, and the Equitable Care of Patients