States are learning to use leverage for social good and to save money

Increasingly, government agencies, health plans, consumer groups, and advocates are expressing concern about the disparities in health care services for racial and ethnic minorities. Some groups are finding ways to address these disparities, and finding that in the process, they are improving the quality of care and saving money. In this issue we look at the extent of the problem, its impact on people, and some of the solutions being pursued.

Despite progress made in the United States in ensuring access and delivery of health care services to those who need them, there still are points at which the system may fail to meet the needs of racial and ethnic minorities, from insurance coverage to access to appropriate services.

The National Academy for State Health Policy (NASHP) in Portland, ME, says states, as major purchasers of health care services, have a number of tools to address disparities in care.

The most common — translation and interpreter services — are not sufficient, however, and states are starting to use their purchasing and regulatory authority to make more of a difference.

On average, according to a NASHP report, Latinos and African-Americans have worse health status and access to effective health care than whites. On most measures, African-Americans are the most disadvantaged population, while on most measures of access to care, Latinos are worse off.

Health disparities increase costs and reduce quality of life. Diabetes, for example, which disproportionately affects racial and ethnic minorities, costs about $100 billion annually in direct medical and treatment costs and indirect costs attributed to disability and mortality. Reducing disparities in diabetes health care prevention and treatment strategies would reduce unnecessary illness, disability, death, and expense.

Likewise, asthma detection, intervention, and treatment could reduce hospitalizations, disability, and deaths that disproportionately affect racial and ethnic minorities. Direct and indirect asthma costs are estimated to be more than $6 billion a year.

Too early to assess effectiveness

NASHP project manager Jill Rosenthal tells State Health Watch that it’s still too early to assess the effectiveness of many state efforts, although the assumption is that they will lead to change.

She says that in spite of the growing attention being paid to the problem, the issue of racial disparities can slip through the cracks if state officials fail to focus on it. Clear goals, benchmarks, and coordination of efforts are needed if results are to be seen, she adds.

NASHP’s survey found that many state health care purchasers do not analyze service utilization, quality improvement, patient satisfaction, or other data sets by race and ethnicity. Many purchasers noted the need for a common data set and more specific data about their racial and ethnic minority populations.

"Crude categories for capturing race and ethnicity make it difficult to identify the needs of specific populations," the report states. "Lack of data and performance measurement have left state purchasers without information to determine how to use resources most effectively to identify risk factors and develop interventions."

Agencies that purchase health care may address disparities through direct state activities and state contract requirements that address language and cultural barriers, outreach activities, collection and analysis of data for utilization and/or patterns of care, and quality improvement efforts that examine and improve the care provided to members of racial and ethnic minority groups or for conditions that disproportionately affect members of minority groups.

Neva Kaye, NASHP’s program director, tells State Health Watch that state efforts should not be totally limited to cultural competency.

Ms. Rosenthal notes that some state efforts, such as disease management programs, are seen as ways to improve care rather than efforts specifically intended to reduce disparities, making it hard to accurately assess how much really is being done.

Responses to NASHP from 28 state Offices of Minority Health indicated that 14 of the state purchasing agencies such as Medicaid, State Children’s Health Insurance Program (SCHIP), and state employee benefits agencies, are using purchasing strategies to reduce racial and ethnic health disparities. (To view purchasing strategies, see chart 1 and chart 2.)

Many reasons that states act

Factors that led states to use their purchasing power as a disparity reduction strategy included data that increased awareness of poor health outcomes for minorities, changing racial demographics, federal regulations related to availability of services for racial and ethnic minorities, availability of state funding to address disparities, community input, the cost of disparities, and state agency commitment to quality and public health.

Eleven of the 28 reporting states indicated they use regulatory strategies to reduce disparities, with the most commonly used regulatory strategy aimed at increasing cultural and linguistic access to health services. 

The academy survey found that state strategies vary depending on population needs and evolving capacity. Despite the increasing attention being paid to the issue, state strategies still may not be strategic or focused, and states may not have the performance measures and data needed to assess the problem and develop solutions.

New York State Department of Health Division of Family Health associate director Karen Kalaijian tells State Health Watch that the state’s diverse population has led to significant efforts to overcome disparities in Medicaid managed care.

In the Medicaid managed care waiver project under way in 21 counties and most of New York City, she says, about 69% of enrollees are non-Caucasian. And in New York City, there are many ethnic minorities included within the overall Caucasian grouping.

"We’re very cognizant of the need to make this program acceptable to persons with very limited proficiency in English," she says.

"We go to a lot of effort to be sure we can find physicians who can meet their needs within our plans."

Health plans wanting to contract with the state must go through a qualification process showing how they will meet beneficiary requirements, including cultural competencies and how they will meet the needs of diverse populations.

Plans must have sufficient providers in geographic areas in which ethnic or racial groups are found and must have staff with language capability for the populations they serve.

They must provide access to the physically disabled, have quality assurance plans, have written quality improvement protocols, and have a member-services function to communicate with enrollees.

During new member screenings, plan physicians are expected to identify special health needs and cultural needs. Informational and marketing materials must be published in languages other than English if at least 5% of the enrollees speak another language.

To improve access to health care services, the state agency contracts with community-based organizations to assist in outreach and enrollment activities.

Ms. Kalaijian says the organizations are encouraged to hire staff that are culturally and linguistically appropriate, that must be able to work in more than 38 languages across the state.

While people can opt out of managed care if they can demonstrate language barriers, she says only seven of more than 300 such requests in New York City had to be granted. In all other cases, enrollees were directed to providers who spoke their language.

Special issues with women

Under leadership of former U.S. Surgeon General Antonia Novello, Kalaijian says, New York state is trying to recognize cultural differences in approaches to health care. For instance, in the Hispanic culture, women put their families first and would be the last to go to the doctor. The agency is working to help Hispanic women to accept that if they care for themselves first, they will be better able to care for their families.

In Massachusetts, Group Insur-ance Commission executive director Dolores Mitchell tells State Health Watch that her general approach is to be sensitive to cultural differences and needs wherever there is an opportunity. Often, she says, there are basic issues to be resolved.

"For instance, access may not mean whether a person has insurance coverage but whether he or she has transportation to be able to get to a health fair. You have to bring programs to poor neighborhoods and not just hold them downtown."

Ms. Mitchell’s commission maintains contracts with smaller neighborhood health center-based plans that otherwise might not meet contracting criteria and makes sure they offer materials in multiple languages. And her staff use yearly HMO site visits to ask providers what steps they take taking to demonstrate cultural sensitivity and competence and to leave a message about concerns that Mitchell wants to see pursued.

Beth Waldman, MassHealth’s director of program implementation, says the agency is concerned with overcoming disparities in getting people to apply for Medicaid and then getting them quality care once they are enrolled.

Of the one million MassHealth members, about one-third are racial or ethnic minorities and 15% are self-identified as speaking a primary language other than English.

Ms. Waldman says they try to enhance the patient-doctor relationship to enhance the clinical care process. Providers are encouraged to use trained medical interpreters and to employ appropriately bilingual staff.

Translated materials available

On the member side, MassHealth has expanded availability of translated materials. Staff make efforts, she says, to communicate information correctly in appropriate dialects. Materials are targeted to groups in specific geographic areas, and minigrants have been given to community-based organizations to facilitate outreach in targeted communities.

State efforts to eliminate disparities can be helped by more collaboration among state agencies, NASHP says.

Often, Ms. Rosenthal says, agencies may not be aware of each other’s roles and mutual interests. For instance, state Offices of Minority Health may not be actively involved in state purchasing or regulation of health care as a strategy to reduce disparities. Strong leadership can overcome these shortcomings and force action.

Ms. Mitchell says she feels strongly that overcoming racial and ethnic disparities is the right thing to do and should not be subjected to a cost-benefit analysis.

"I can be hard-headed about what things cost and what we can expect to get from them," she says.

"But I don’t think cost benefit matters when it comes to this issue. As a major purchaser of health care services, if we decide certain things need to be done, we tell the plans, Do it because I’m the purchaser and I say so.’ Whatever leverage you have as a large purchaser, you should use it for social good as well as cost savings," Ms. Mitchell points out.

[Contact Ms. Rosenthal and Ms. Kaye at (207) 874-6524, Ms. Kalaijian at (518) 473-1134, Ms. Mitchell at (617) 727-2310, and Ms. Waldman at (617) 210-5371.]