Racial/Ethnic Disparities and Health Policy


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  • Medicare Services Study showed variation in health care utilization based on race/ethnicity for: Mammography Amputations Influenza vaccination Summary point of study: “Providing health insurance is not enough to ensure that the program is used effectively and equitably by all beneficiaries.”
  • (bullet one)…that disparities exist and that addressing them is important to the hospital.
  • My colleagues have given you an overview of the approach that we’ve taken to address the problem of racial and ethnic disparities at the health systems level. I’d like to now focus in specifically on one example of how we plan to link data directly to action to eliminate disparities. In 2004 several investigators at MGH began looking at data from a new diabetes registry that had been established to track quality indicators among diabetics. Some of the impetus for this registry had to do with managed care “pay for performance” programs that withhold a portion of funds from provider networks that don’t achieve certain quality indicators and awarded these funds to those who do. It turned out that several of the community health centers were not meeting diabetes quality targets, and these health centers also happened to have a higher minority patient population. It also turned out that even within these health centers, we found significant disparities between whites and minorities. MGH took a particular interest in the Chelsea Health Center which has the highest proportion of Latino patients of all the MGH ambulatory care sites. What we found was that in general …(slide) So we were tasked by Peter Slavin, the president of the Hospital, to work in collaboration with the team at Chelsea (including Tom Stern, Lynne Brodsky and Sarah Oo), Joan Quinlan of the community benefits office at MGH, and May Chin of the MGH physicians organization, to come up with a “solution” (I say solution in parens since it’s never as simple as it sounds - but here’s what we came up with)
  • Racial/Ethnic Disparities and Health Policy

    1. 1. Racial/Ethnic Disparities and Health Policy A View from the Field Joseph R. Betancourt, M.D., M.P.H. Director, The Disparities Solutions Center Senior Scientist, Institute for Health Policy Director for Multicultural Education, Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School
    2. 2. Outline <ul><li>The US Healthcare System </li></ul><ul><li>Quality, Racial/Ethnic Disparities, and Key Clinical Lessons </li></ul><ul><li>Health Care Reform: Implications for Disparities </li></ul><ul><li>A View from the Field </li></ul>
    3. 3. The US Healthcare System Background and Context <ul><li>Patchwork system of Health Insurance </li></ul><ul><ul><li>Employer-Based Health Insurance Dominant </li></ul></ul><ul><ul><li>Government Programs </li></ul></ul><ul><ul><ul><li>Medicaid: Low-income women and children </li></ul></ul></ul><ul><ul><ul><li>SCHIP: Low to moderate income children </li></ul></ul></ul><ul><ul><ul><li>Medicare: Universal Access > 65, disabled, HD </li></ul></ul></ul><ul><ul><ul><li>Special Populations (VA, DoD, IHS) </li></ul></ul></ul><ul><li>Lack of Insurance a Major Issue </li></ul><ul><ul><li>46-50 Million Americans Uninsured </li></ul></ul><ul><ul><li>Minorities, immigrants over-represented among these </li></ul></ul><ul><ul><ul><li>Latinos 13% of population, 25% of uninsured </li></ul></ul></ul>
    4. 4. The US Healthcare System Background and Context <ul><li>Healthcare Expenditures Increasing </li></ul><ul><ul><li>Technology, Pharma, End-of-Life, Regional Variation </li></ul></ul><ul><ul><li>Cost as part of GDP no longer sustainable </li></ul></ul><ul><ul><li>Expenditures don’t translate to leading indicators </li></ul></ul><ul><ul><ul><li>Infant Mortality as an example </li></ul></ul></ul><ul><ul><li>Health care reform on horizon; in place in MA </li></ul></ul><ul><li>California budget issues strain services </li></ul><ul><ul><li>Issues magnified in state with high uninsured, immigrants </li></ul></ul><ul><ul><li>Health and human services particularly affected </li></ul></ul>
    5. 5. The US Healthcare System Background and Context <ul><li>Quality of Health Care Suboptimal </li></ul><ul><ul><li>Patients receive recommended services only 54% of the time </li></ul></ul><ul><ul><li>New focus on improving quality </li></ul></ul><ul><li>Racial/Ethnic Disparities in Health Care </li></ul><ul><ul><li>Minorities receive lower quality health care even when controlling for SES, insurance status, comorbidities, stage of presentation </li></ul></ul><ul><ul><li>New focus on achieving equity </li></ul></ul>
    6. 6. Diabetes-Related Death Rate, 2006 Deaths per 100,000 population
    7. 7. Racial/Ethnic Disparities in Health Care <ul><li>In patients with insurance… </li></ul><ul><ul><li>Disparities based on race for: </li></ul></ul><ul><ul><ul><li>Influenza vaccination (Gornick et al.) </li></ul></ul></ul><ul><ul><ul><li>Lung Ca Surgery (Bach et al.) </li></ul></ul></ul><ul><ul><ul><li>Renal Transplantation (Ayanian et al.) </li></ul></ul></ul><ul><ul><ul><li>Treatment of chest pain, cardiac catheterization, angioplasty, bypass (Harris et al, Ayanian et al., Peterson et al., Johson et al.) </li></ul></ul></ul><ul><ul><ul><li>Referral to cardiology specialist care (Schulman et al.) </li></ul></ul></ul><ul><ul><ul><li>Treatment of HIV/AIDS (Shapiro et al.) </li></ul></ul></ul><ul><ul><ul><li>Pain management (Todd et al.) </li></ul></ul></ul>
    8. 8. Disparities in Health Care Key Clinical Lessons from Unequal Treatment
    9. 9. Minorities Face Greater Difficulty in Communicating with Physicians Base: Adults with health care visit in past two years. * Problems include understanding doctor, feeling doctor listened, had questions but did not ask. Source: The Commonwealth Fund 2001 Health Care Quality Survey. Percent of adults with one or more communication problems*
    10. 10. Clinical Decisionmaking and Stereotyping <ul><li>Automatic aspects; group  individual </li></ul><ul><li>“ Cognitive Misers”  cognitive shortcuts to save resources; principle of “least effort” </li></ul><ul><li>Primal->race, gender, age </li></ul><ul><li>Activated most when: </li></ul><ul><ul><li>Stressed </li></ul></ul><ul><ul><li>Under time constraints </li></ul></ul><ul><ul><li>Multitasking </li></ul></ul>
    11. 11. The Patient Perspective: Unequal Treatment Kaiser Family Foundation Survey, 2000 Percent
    12. 12. <ul><li>Quality Health Care </li></ul><ul><li>Health care should be </li></ul><ul><ul><li>Safe </li></ul></ul><ul><ul><li>Effective </li></ul></ul><ul><ul><li>Patient-centered </li></ul></ul><ul><ul><li>Timely </li></ul></ul><ul><ul><li>Efficient </li></ul></ul><ul><ul><li>Equitable </li></ul></ul>
    13. 13. Linking Disparities to Quality <ul><li>Safe </li></ul><ul><ul><li>Minorities have more medical errors with greater clinical consequences </li></ul></ul><ul><li>Effective </li></ul><ul><ul><li>Minorities received less evidence-based care (diabetes) </li></ul></ul><ul><li>Patient-centered </li></ul><ul><ul><li>Minorities less likely to provide truly informed consent </li></ul></ul><ul><li>Timely </li></ul><ul><ul><li>Minorities more likely to wait for same procedure (transplant) </li></ul></ul><ul><li>Efficient </li></ul><ul><ul><li>More test ordering in ED for minorities due to poor communication </li></ul></ul><ul><li>Also </li></ul><ul><ul><li>Minorities have more CHF readmissions, ACS admissions, and longer length of stay for the same condition </li></ul></ul>
    14. 14. IOM’s Unequal Treatment www.nap.edu <ul><li>Recommendations </li></ul><ul><li>Increase awareness of existence of disparities </li></ul><ul><li>Address systems of care </li></ul><ul><ul><li>Support race/ethnicity data collection, quality improvement, evidence-based guidelines, multidisciplinary teams, community outreach </li></ul></ul><ul><ul><li>Improve workforce diversity </li></ul></ul><ul><ul><li>Facilitate interpretation services </li></ul></ul><ul><li>Provider education </li></ul><ul><ul><li>Health Disparities, Cultural Competence, Clinical Decisionmaking </li></ul></ul><ul><li>Patient education (navigation, activation) </li></ul><ul><li>Research </li></ul><ul><ul><li>Promising strategies, Barriers to eliminating disparities </li></ul></ul>
    15. 15. Key Issues Addressing Disparities in the Context of Quality and Reform
    16. 16. Need for Innovation Key Challenges to Quality and Equity <ul><li>Primary Care and Nursing Shortage </li></ul><ul><ul><li>Specialty shortage in certain areas </li></ul></ul><ul><li>Productivity requirements, short medical visits </li></ul><ul><ul><li>Little time for review, education, counseling </li></ul></ul><ul><li>Reimbursement for procedures, episodes </li></ul><ul><ul><li>Little incentive for coordinated care </li></ul></ul><ul><li>Defensive and “Patient Satisfaction” Medicine </li></ul><ul><ul><li>Procedures, Prescriptions </li></ul></ul><ul><li>Greater call for documentation </li></ul><ul><ul><li>Pros and cons of the EMR </li></ul></ul><ul><li>New efforts in P4P </li></ul><ul><ul><li>Metrics, measures, and impact on disparities </li></ul></ul>
    17. 17. Need for Innovation Health Care Reform Principles <ul><li>Increase Access </li></ul><ul><ul><li>Employer, Individual Mandate, Elimination of pre-existing conditions </li></ul></ul><ul><ul><li>Competitive insurance products via new market; Gov’t support </li></ul></ul><ul><ul><ul><li>Public Option/Co-Op’s? </li></ul></ul></ul><ul><li>Improve Quality </li></ul><ul><ul><li>Effective care via evidenced-based practice </li></ul></ul><ul><ul><ul><li>Disease Management, new efforts in wellness </li></ul></ul></ul><ul><ul><li>Health Information Technology </li></ul></ul><ul><ul><ul><li>PHR, EMR, CDM and Decision Support </li></ul></ul></ul><ul><li>Bending the Cost Curve </li></ul><ul><ul><li>Payment Reform </li></ul></ul><ul><ul><ul><li>Provider changes, P4P, Medical Home, Accountable Organizations </li></ul></ul></ul><ul><ul><li>Savings from improving quality </li></ul></ul><ul><ul><ul><li>Decreasing redundancy, inappropriate utilization </li></ul></ul></ul>
    18. 18. A View from the Field Current Context and Strategies to Address Racial/Ethnic Disparities in Health Care
    19. 19. Accreditation, Quality Measures, Employer Leverage <ul><li>NCQA </li></ul><ul><ul><li>New efforts in disparities </li></ul></ul><ul><ul><li>Measures released in 2009 </li></ul></ul><ul><li>Joint Commission </li></ul><ul><ul><li>New project on culture, health and disparities </li></ul></ul><ul><ul><li>New disparities/cultural competence accreditation standards 2007, completed public comment, plan for release in 2010-11 </li></ul></ul><ul><li>National Quality Forum </li></ul><ul><ul><li>Developed cultural competence quality measures in 2009 </li></ul></ul><ul><li>National Business Group on Health </li></ul><ul><ul><li>Developed major effort to educate employers about disparities, including making the business case; brief released in 2009 </li></ul></ul>
    20. 20. A View from the Field <ul><li>Building Equitable Systems and Incentives </li></ul><ul><li>Race/ethnicity data collection </li></ul><ul><li>Quality improvement plans and incentives to achieve goals (P4P) </li></ul><ul><li>Increase Capacity of Health Care Providers </li></ul><ul><li>Foster cultural competence of health care providers </li></ul><ul><li>Empower Patients </li></ul><ul><li>Support navigation and educational activities </li></ul><ul><li>20/80 Rule: NHDR </li></ul><ul><li>Asthma, Diabetes, CVD, CRC Screen, Mental Health </li></ul>
    21. 21. Identifying and Benchmarking Disparities: The Example of MGH <ul><li>Medical Policy </li></ul><ul><ul><li>All QI stratified by race/ethnicity </li></ul></ul><ul><li>Unit-Based Staff Quality Rounds </li></ul><ul><ul><li>Exploring potential disparities-causing events </li></ul></ul><ul><li>Patient Satisfaction </li></ul><ul><ul><li>Stratify results by r/e and added questions about respect for culture/race/religion </li></ul></ul><ul><li>Nat’l Hosp Qual Measures, HEDIS Measures </li></ul><ul><ul><li>Stratifying results by race/ethnicity </li></ul></ul><ul><li>Disparities Dashboard </li></ul><ul><ul><li>Report routinely to leadership </li></ul></ul>
    22. 22. We are including the Core Measures for Heart Attack, Heart Failure and Pneumonia.
    23. 23. Need for Innovation Models at Massachusetts General Hospital <ul><li>Health Coaches </li></ul><ul><ul><li>Based at health care delivery site </li></ul></ul><ul><ul><li>Assist with chronic disease management (ex. Diabetes) </li></ul></ul><ul><li>Health Care Navigators </li></ul><ul><ul><li>Based at health care delivery site </li></ul></ul><ul><ul><li>Assist with health promotion (cancer screening) and disease prevention (cancer progression) </li></ul></ul><ul><li>Community Health Workers </li></ul><ul><ul><li>Based in community, visit home </li></ul></ul><ul><ul><li>Assist with chronic disease management (ex. Asthma) </li></ul></ul>
    24. 24. The MGH Chelsea Diabetes Program <ul><li>Chelsea: Large minority and immigrant community (Hispanic/Latino primarily, but also Bosnian, Somali) about 3 miles from hospital. MGH Chelsea Healthcare Center provides community based care </li></ul><ul><li>MGH Chelsea Diabetes Program: A quality improvement / disparities reduction program with 3 primary components: </li></ul><ul><ul><li>Telephone outreach to increase rate of HbA1c testing </li></ul></ul><ul><ul><li>Individual coaching to address patients’ needs and concerns regarding diabetes self-management to improve HbA1c (1500 visits, 400 routine patients seen) </li></ul></ul><ul><ul><li>Group education meeting ADA requirements (150 patients) </li></ul></ul>
    25. 25. * Chelsea Diabetes Management Program began in first quarter of 2005; in 2008 received Diabetes Coalition of MA Programs of Excellence Award * Decrease in target group HgbA1c 1.5
    26. 26. Need for Innovation Health Care Reform Disparities Provisions and Analysis <ul><li>Increase Access </li></ul><ul><ul><li>Will help address disparities </li></ul></ul><ul><li>Improve Quality </li></ul><ul><ul><li>Specific disparities-related provisions and resources for: </li></ul></ul><ul><ul><ul><li>Race/Ethnicity Data Collection </li></ul></ul></ul><ul><ul><ul><li>Disease Management </li></ul></ul></ul><ul><ul><ul><li>Health Information Technology </li></ul></ul></ul><ul><ul><ul><li>Workforce Diversity and Cultural Competence Training </li></ul></ul></ul><ul><li>Bending the Cost Curve </li></ul><ul><ul><li>Payment Reform </li></ul></ul><ul><ul><ul><li>Provider changes, Medical Home, Accountable Organizations should help address disparities; ? P4P </li></ul></ul></ul><ul><ul><ul><li>Funding for interpreter services </li></ul></ul></ul>
    27. 27. Implications for Small Practices What can you do? <ul><li>Monitor Quality by Particular Characteristics </li></ul><ul><ul><li>Collect race/ethnicity data </li></ul></ul><ul><ul><li>Assess via chart audit, or through EMR </li></ul></ul><ul><li>Partner with other organizations/Develop interventions </li></ul><ul><ul><li>Community-Based Organizations </li></ul></ul><ul><ul><ul><li>CHW’s </li></ul></ul></ul><ul><ul><li>Major Associations (ADA, AHA) </li></ul></ul><ul><ul><ul><li>Coaches, Promotoras, Navigators </li></ul></ul></ul><ul><ul><li>Private Industry/Pharma </li></ul></ul><ul><ul><ul><li>Key educational resources </li></ul></ul></ul><ul><li>Keep up-to-date on services, resources </li></ul><ul><li>Continued policy and advocacy </li></ul>
    28. 28. Summary <ul><li>There is a significant body of evidence that demonstrates the challenges of moving forward with our health care system </li></ul><ul><li>Health care reform impending, implications for quality and disparities are clear </li></ul><ul><li>As providers we must stay engaged in the debate, create high-quality systems, and use positions of advocacy </li></ul>