Hedge Funds 2/28/04 POLICIES TO REDUCE DISPARITIES IN  CHILD HEALTH CARE  Anne C. Beal, MD, MPH President Aetna Foundation...
Disparities in Child Health Status  and Healthcare Are Real <ul><li>African American infant mortality rate 2.5 times highe...
<ul><li>Disparities Are Here in Westchester </li></ul>
Black Infants are Four Times More  Likely to Die than White Infants in Westchester Deaths per 1,000 Live Births, 2004 Sour...
Black Children Are Three Times  More Likely to Die Than  White Children in Westchester Deaths per 1,000 Population, 2004 S...
Average Length of Stay for Pediatric  Hospitalization By Race, 2004 Source: 2005 Annual Data Book. http://www.westchesterg...
WHICH HEALTH DISPARITIES <ul><li>Health Outcomes </li></ul><ul><li>Life Expectancy </li></ul><ul><li>Health Status </li></...
WHICH HEALTH DISPARITIES Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadi...
Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Fram...
What Causes Disparities? Co-Morbid Conditions Access To Care/Coverage Quality of Healthcare Patient Adherence Genetic Pred...
WHAT CAUSES DISPARITIES? Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors ...
WHAT CAUSES DISPARITIES? Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors ...
<ul><li>Is This About Race/Ethnicity or About Coverage? </li></ul>
Minority Children are More Likely  to Lack Insurance Coverage 23 20 23 37 Percent of Children Ages 0-18 Uninsured All or P...
Racial Disparities in Clinical Quality  Occur Among the Insured Source: Eric C. SchneiderM.D., Alan M. Zaslavsky, Arnold M...
What Does it Really Take  to Improve Care and  Reduce Health Disparities? <ul><li>Health care system comprised of purchase...
<ul><li>Health Care Coverage </li></ul>
State Children’s Health Insurance  Program (SCHIP) <ul><li>Designed to provide coverage to low income children not eligibl...
Expand SCHIP Eligibility <ul><li>Universal Health Care </li></ul><ul><li>Uniform requirements for SCHIP eligibility </li><...
Health Care Costs $6 Billion Over 5 Years $2.3 trillion in 2008
<ul><li>Monitor the Quality of Care </li></ul>Stratified by Race/Ethnicity
Disparities in Healthcare  and Quality of Care <ul><li>Measures of healthcare disparities are essentially quality measures...
COLLECTING RATE/ETHNICITY DATA: The First Step for Achieving Equity <ul><li>Barriers, is it legal? </li></ul><ul><li>How t...
Quality Improvement Reduces Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 Source: Ada...
Quality Improvement Could  Maintain Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 46 ...
Quality Improvement Could  Worsen Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 46 36...
<ul><li>Health Care Is Separate </li></ul><ul><li>and Unequal </li></ul>
Percent of adults 18–64  LARGE PROPORTIONS OF MINORITY PATIENTS  USE PRIVATE DOCTORS AS  THEIR REGULAR SOURCE OF CARE   * ...
CARE FOR MINORITY PATIENTS IS  CONCENTRATED AMONG A FEW PROVIDERS Half of All Minority Patients Are Treated by One-Third o...
Source: David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, and Vincent Mor,Separate And Unequal: Raci...
PRACTICES WITH MORE MINORITY PATIENTS  REPORT MORE PROBLEMS WITH QUALITY Percent Quality Problems by Proportion of Minorit...
<15% Black 15-35% Black >35% Black NE  MW South West % Black Region NICU Volume >40 Infants <40 Infants Odds Ratio Source:...
<ul><li>High Quality Care Promotes Equity </li></ul>
Source: Commonwealth Fund 2006 Health Care Quality Survey. Hispanics Are Least Likely to Report Their Providers Have Indic...
Percent of adults 18--64 reporting always getting care when they need it *Compared to Whites, differences remain statistic...
Racial and Ethnic Differences in Getting  Needed Medical Care Are Eliminated When Adults Have Medical Homes Percent of adu...
*Compared to Whites, differences remain statistically significant after adjusting for income or insurance Source: 2006 Com...
Minorities Who Have Medical Homes  Have More Rapid Access to  Medical Appointments Percent of adults 18–64 able to get an ...
<ul><li>Health Care Providers </li></ul>
Cultural Competency Improves  Quality of Care Preventive medication underuse among children with persistent asthma Cultura...
Promoting Cultural Competency in Healthcare Raise Awareness Develop Measures of Processes and Outcomes Set Standards for P...
Workforce Diversity <ul><li>Physicians of color more likely to serve in low-income and underserved communities and care fo...
People of Color Are Underrepresented  in College, Medical School and  as Medical Faculty Percent of Students from Underrep...
What Does it Take to Eliminate  Disparities in Care? <ul><li>Health Care Coverage </li></ul><ul><li>Quality Improvement </...
<ul><li>An Aetna Foundation Priority: </li></ul><ul><li>Racial and Ethnic Equity in Health and Health Care </li></ul>
LOOKING AHEAD:  The Foundation’s National Program Areas <ul><li>Obesity To address the rising rate of obesity among U.S. a...
CONTACT US E-mail the Aetna Foundation: [email_address] Aetna Foundation website: www.AetnaFoundation.org Call for Proposa...
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Disparities in Children's Health

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Anne C. Beale, MD, MPH, the president of the Aetna Foundation speaks about disparities in child health care, the causes behind those disparities, and policies that can reduce them.

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  • Cultural competence (policies included in summary score)   Recruits ethnically diverse nurses and providers49 (71.0)   Recruits bilingual nurses and providers40 (58.0)   Attempts to minimize cultural barriers through printed materials34 (48.6)   Offers cross-cultural or diversity training26 (39.4)   Offers training to providers to develop communication skills16 (23.5)   Evaluates the level of cultural competence among providers9 (14.5)  Cultural competence summary score (0–6).85  5–611 (18.6)  3–416 (27.1)  1–222 (37.3)  010 (17.0)  Communication-related practices   Offers access to interpreters52 (74.3)   Provides interpreter service via telephone41 (63.1)   Provides low-literacy health educational materials41 (59.4)
  • Relative weight of each factor has yet to be determined. May vary according to diabetes outcome-prevalence, sequelae, mortality.
  • Relative weight of each factor has yet to be determined. May vary according to diabetes outcome-prevalence, sequelae, mortality.
  • “ Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care” Found significant disparities in care among Medicare beneficiaries for HEDIS measures of breast cancer screening, diabetic eye exam, beta blocker use, and mental illness follow-up (new measure). For example, 54 percent of White beneficiaries received appropriate follow-up after hospitalization for mental illness, compared with 33% of African American beneficiaries. Also found that African Americans were more likely to be enrolled in plans with lower overall quality IOM report – Key findings and recommendations from the report include: Racial and ethnic disparities in health care exist even when insurance status, income, age and severity of conditions are comparable Many sources – including health systems, helath care providers, patients and health plan managers contribute to these disparities Steps need to be taken to increase awareness of disparities among providers, the general public and key stakeholders Strengthening the stability of relationships between patients and providers in publicly funded health plans Promoting consistency and equity in health care through the use of evidence based guidelines Collecting and reporting data on health care access and utilization by patients’ race, ethnicity, SES and where possible, primary language
  • States have increased enrollment by raising awareness and simplifying enrollment process
  • Even if children of color gain access to care, they may experience poor-quality care Quality improvement would therefore reduce disparities. Funding programs such as Medicaid typically reimburse at below market rates, and most safety net health systems suffer from chronic underfunding and shortages in resources. As a result, they have fewer resources and are less able to provide high quality care than better resourced health systems.
  • Figure29 from closing the divide
  • Cultural competence (policies included in summary score)   Recruits ethnically diverse nurses and providers49 (71.0)   Recruits bilingual nurses and providers40 (58.0)   Attempts to minimize cultural barriers through printed materials34 (48.6)   Offers cross-cultural or diversity training26 (39.4)   Offers training to providers to develop communication skills16 (23.5)   Evaluates the level of cultural competence among providers9 (14.5)  Cultural competence summary score (0–6).85  5–611 (18.6)  3–416 (27.1)  1–222 (37.3)  010 (17.0)  Communication-related practices   Offers access to interpreters52 (74.3)   Provides interpreter service via telephone41 (63.1)   Provides low-literacy health educational materials41 (59.4)
  • More involved with medical decision making
  • Many programs receive funding from several HRSA program President’s budget for fiscal year 2005 calls for a 96 reduction from $294 million in 2004 Health Education and Disempowerment Zone
  • Overall coordination and monitoring of efforts to reduce disparities Will promote research, public health and health promotion efforts
  • Disparities in Children's Health

    1. 1. Hedge Funds 2/28/04 POLICIES TO REDUCE DISPARITIES IN CHILD HEALTH CARE Anne C. Beal, MD, MPH President Aetna Foundation, Inc .
    2. 2. Disparities in Child Health Status and Healthcare Are Real <ul><li>African American infant mortality rate 2.5 times higher than whites </li></ul><ul><li>African American children 3 times more likely to be hospitalized for asthma </li></ul><ul><li>When hospitalized, African American are one third less likely to be discharged with prescriptions for routine meds to prevent future asthma-related hospitalizations (7% vs 21%) </li></ul><ul><li>African-American and Hispanic children represented more than 80 percent of pediatric AIDS cases in 2000 </li></ul><ul><li>Death rates for African American children are 40% higher than the national average </li></ul>
    3. 3. <ul><li>Disparities Are Here in Westchester </li></ul>
    4. 4. Black Infants are Four Times More Likely to Die than White Infants in Westchester Deaths per 1,000 Live Births, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf
    5. 5. Black Children Are Three Times More Likely to Die Than White Children in Westchester Deaths per 1,000 Population, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf
    6. 6. Average Length of Stay for Pediatric Hospitalization By Race, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf
    7. 7. WHICH HEALTH DISPARITIES <ul><li>Health Outcomes </li></ul><ul><li>Life Expectancy </li></ul><ul><li>Health Status </li></ul><ul><li>Asthma Rates </li></ul><ul><li>Diabetes Rates </li></ul><ul><li>Non-Medical </li></ul><ul><li>Health Behaviors </li></ul><ul><li>Living and Working Conditions </li></ul><ul><li>Income </li></ul><ul><li>Stress </li></ul><ul><li>Healthcare </li></ul><ul><li>Acceptability </li></ul><ul><li>Access </li></ul><ul><li>Effectiveness </li></ul><ul><li>Safety </li></ul><ul><li>Financing </li></ul>
    8. 8. WHICH HEALTH DISPARITIES Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level. BMC Health Services Research. 5:76. 40%-67% 44%-57% <ul><li>Health Outcomes </li></ul><ul><li>Life Expectancy </li></ul><ul><li>Health Status </li></ul><ul><li>Asthma Rates </li></ul><ul><li>Diabetes Rates </li></ul><ul><li>Non-Medical </li></ul><ul><li>Health Behaviors </li></ul><ul><li>Living and Working Conditions </li></ul><ul><li>Income </li></ul><ul><li>Stress </li></ul><ul><li>Healthcare </li></ul><ul><li>Acceptability </li></ul><ul><li>Access </li></ul><ul><li>Effectiveness </li></ul><ul><li>Safety </li></ul><ul><li>Financing </li></ul>
    9. 9. Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level. BMC Health Services Research. 5:76. What Causes Disparities? -0.783 Heavy Drinking +0.821 Income +0.872 Physicians +0.836 Unemployment -0.814 -0.727 Per Capita Health Expenditure +0.652 Life Stress Life Expectancy Diabetes Asthma
    10. 10. What Causes Disparities? Co-Morbid Conditions Access To Care/Coverage Quality of Healthcare Patient Adherence Genetic Predisposition Community Factors Environmental Factors Cultural Factors Economic Factors Physiologic Response to Meds Ease of Lifestyle Changes
    11. 11. WHAT CAUSES DISPARITIES? Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Patient Adherence Ease of Lifestyle Changes Physiologic Response to Meds Disparities
    12. 12. WHAT CAUSES DISPARITIES? Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Patient Adherence Ease of Lifestyle Changes Physiologic Response to Meds Disparities
    13. 13. <ul><li>Is This About Race/Ethnicity or About Coverage? </li></ul>
    14. 14. Minority Children are More Likely to Lack Insurance Coverage 23 20 23 37 Percent of Children Ages 0-18 Uninsured All or Part Year, 2000 Source: Adapted from Doty, MM. Insurance, Access, and Quality of Care Among Hispanic Populations. 2003 Chartpack. The Commonwealth Fund and Columbia University analysis of MEPS 2000.
    15. 15. Racial Disparities in Clinical Quality Occur Among the Insured Source: Eric C. SchneiderM.D., Alan M. Zaslavsky, Arnold M. Epstein, M.D. “Racial Disparities in Quality of Care for Enrollees in Medicare Managed Care.” Journal of the American Medical Association, vol. 287, no. 10 Percent of Medicare managed care beneficiaries receiving service
    16. 16. What Does it Really Take to Improve Care and Reduce Health Disparities? <ul><li>Health care system comprised of purchasers, providers, regulators, researchers, educators, and others. </li></ul><ul><li>Need a multifaceted approach that affects the different sectors of the health system </li></ul>
    17. 17. <ul><li>Health Care Coverage </li></ul>
    18. 18. State Children’s Health Insurance Program (SCHIP) <ul><li>Designed to provide coverage to low income children not eligible for Medicaid </li></ul><ul><li>Estimated that fewer than half of all eligible children are enrolled </li></ul><ul><li>If every child who was eligible for either Medicaid or SCHIP was enrolled </li></ul><ul><ul><li>6.7 million </li></ul></ul><ul><ul><li>76% </li></ul></ul>
    19. 19. Expand SCHIP Eligibility <ul><li>Universal Health Care </li></ul><ul><li>Uniform requirements for SCHIP eligibility </li></ul><ul><ul><li>from 133% to 400% FPL </li></ul></ul><ul><ul><li>39 states have caps of at least 200% * </li></ul></ul><ul><li>Raise SCHIP eligibility cap to 300% FPL </li></ul><ul><ul><li>7.9 million </li></ul></ul><ul><ul><li>90.3% of uninsured children </li></ul></ul>*$41,300 for a family of four in 2007
    20. 20. Health Care Costs $6 Billion Over 5 Years $2.3 trillion in 2008
    21. 21. <ul><li>Monitor the Quality of Care </li></ul>Stratified by Race/Ethnicity
    22. 22. Disparities in Healthcare and Quality of Care <ul><li>Measures of healthcare disparities are essentially quality measures. </li></ul><ul><li>Disparities in health is not a marginal or special interest issue. </li></ul><ul><li>There is a larger quality movement; use their tools, language and techniques. </li></ul><ul><li>Calls upon quality movement to address quality for vulnerable patients. </li></ul>
    23. 23. COLLECTING RATE/ETHNICITY DATA: The First Step for Achieving Equity <ul><li>Barriers, is it legal? </li></ul><ul><li>How to collect race/ethnicity data </li></ul><ul><li>What categories? </li></ul><ul><li>How long does it take? </li></ul><ul><li>Who should ask? </li></ul><ul><li>How do patients react? </li></ul>What Do You Do With the Data?
    24. 24. Quality Improvement Reduces Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 Source: Adapted from Sehgal: JAMA, Volume 289(8). February 26, 2003. 996-1000. 46 36 87 84 Adequate Hemodialysis Dose, %
    25. 25. Quality Improvement Could Maintain Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 46 36 87 77 Adequate Hemodialysis Dose, %
    26. 26. Quality Improvement Could Worsen Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 46 36 87 57 Adequate Hemodialysis Dose, %
    27. 27. <ul><li>Health Care Is Separate </li></ul><ul><li>and Unequal </li></ul>
    28. 28. Percent of adults 18–64 LARGE PROPORTIONS OF MINORITY PATIENTS USE PRIVATE DOCTORS AS THEIR REGULAR SOURCE OF CARE * Compared with whites, differences remain statistically significant after adjusting for insurance or income. Source: Commonwealth Fund 2006 Health Care Quality Survey.
    29. 29. CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS Half of All Minority Patients Are Treated by One-Third of Primary Care Physicians Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230 Not an 80:20 rule, but a 80:50 rule
    30. 30. Source: David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, and Vincent Mor,Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes, Health Affairs, Vol 26, Issue 5, 1448-1458 85% 20% CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS
    31. 31. PRACTICES WITH MORE MINORITY PATIENTS REPORT MORE PROBLEMS WITH QUALITY Percent Quality Problems by Proportion of Minority Patients Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230
    32. 32. <15% Black 15-35% Black >35% Black NE MW South West % Black Region NICU Volume >40 Infants <40 Infants Odds Ratio Source: Morales LS et al. Mortality among very low-birthweight infants in hospitals serving minority populations. American Journal of Public Health. Dec 2005. Vol 95, No. 12. Infant Mortality Is Higher in Hospitals with More Minority Patients
    33. 33. <ul><li>High Quality Care Promotes Equity </li></ul>
    34. 34. Source: Commonwealth Fund 2006 Health Care Quality Survey. Hispanics Are Least Likely to Report Their Providers Have Indicators of a Medical Home Among those with a regular doctor or source of care . . . 62 60 65 68 66 93 Doctors’ office visits are always or often well organized and running on time 26 15 34 28 27 47 All four indicators of medical home 66 60 69 65 65 92 Not difficult to get care or medical advice after hours 84 76 82 88 85 121 Not difficult to contact provider over telephone 84 57 79 85 80 142 Regular doctor or source of care Asian American Hispanic African American White Percent Estimated millions Indicator Percent by Race Total
    35. 35. Percent of adults 18--64 reporting always getting care when they need it *Compared to Whites, differences remain statistically significant after adjusting for income Source: 2006 Commonwealth Fund Health Care Quality Survey Hispanics And Asians Are Less Likely to Report Always Getting Medical Care When Needed
    36. 36. Racial and Ethnic Differences in Getting Needed Medical Care Are Eliminated When Adults Have Medical Homes Percent of adults 18–64 reporting always getting care they need when they need it Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey
    37. 37. *Compared to Whites, differences remain statistically significant after adjusting for income or insurance Source: 2006 Commonwealth Fund Health Care Quality Survey Percent of adults 18—64 able to get an appointment same or next day Hispanics and Asians are Less Likely To Get Rapid Access to Medical Appointments
    38. 38. Minorities Who Have Medical Homes Have More Rapid Access to Medical Appointments Percent of adults 18–64 able to get an appointment same or next day * Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey
    39. 39. <ul><li>Health Care Providers </li></ul>
    40. 40. Cultural Competency Improves Quality of Care Preventive medication underuse among children with persistent asthma Cultural Competency Score Source: Lieu TA et al., Cultural Competence Policies and other Predictors of Asthma Care Quality for Medicaid-Insured Children. Pediatrics 114, no. 1 (2003), e102-e110.
    41. 41. Promoting Cultural Competency in Healthcare Raise Awareness Develop Measures of Processes and Outcomes Set Standards for Practice Incorporate into QI
    42. 42. Workforce Diversity <ul><li>Physicians of color more likely to serve in low-income and underserved communities and care for patients of color </li></ul><ul><li>Better results when there is doctor-patient race and language concordance </li></ul><ul><li>25% of US population from underrepresented minority groups; only 11% of medical students are from these groups </li></ul>
    43. 43. People of Color Are Underrepresented in College, Medical School and as Medical Faculty Percent of Students from Underrepresented Groups Source: Manhattan Institute and AAMC Data Warehouse. Previously reported in Beal AC, Abrams M, Saul J. Healthcare Workforce Diversity: Developing Physician Leaders. The Commonwealth Fund. October 2003.
    44. 44. What Does it Take to Eliminate Disparities in Care? <ul><li>Health Care Coverage </li></ul><ul><li>Quality Improvement </li></ul><ul><li>Train Health Care Providers </li></ul><ul><ul><li>Cultural Competency </li></ul></ul><ul><ul><li>Workforce Diversity </li></ul></ul><ul><li>Disparities/Quality Oversight </li></ul>
    45. 45. <ul><li>An Aetna Foundation Priority: </li></ul><ul><li>Racial and Ethnic Equity in Health and Health Care </li></ul>
    46. 46. LOOKING AHEAD: The Foundation’s National Program Areas <ul><li>Obesity To address the rising rate of obesity among U.S. adults and children </li></ul><ul><li>Racial and ethnic health care equity   To promote equity in health and health care for common chronic conditions and infant mortality </li></ul><ul><li>Integrated health care To advance high-quality health care by: </li></ul><ul><ul><li>Improving coordination and communications among </li></ul></ul><ul><ul><li>health care professionals </li></ul></ul><ul><ul><li>Creating informed and involved patients </li></ul></ul><ul><ul><li>Promoting cost-effective, affordable care </li></ul></ul>Beginning in 2010, we will focus our grant-making on issues that lead to meaningful improvements in health and the health care system: 
    47. 47. CONTACT US E-mail the Aetna Foundation: [email_address] Aetna Foundation website: www.AetnaFoundation.org Call for Proposals Was Released March 15, 2010
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