disparities in children's health

Hedge Funds

2/28/04

POLICIES TO REDUCE DISPARITIES IN

CHILD HEALTH CARE

Anne C. Beal, MD, MPHPresident

Aetna Foundation, Inc.

22

HEALTH CARE

EQUITY

2

Disparities in Child Health Status

and Healthcare Are Real• African American infant mortality rate 2.5 times higher

than whites

• African American children 3 times more likely to be hospitalized for asthma

• 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%)

• African-American and Hispanic children represented more than 80 percent of pediatric AIDS cases in 2000

• Death rates for African American children are 40% higher than the national average

33

HEALTH CARE

EQUITY

3

Disparities Are Here in Westchester

44

HEALTH CARE

EQUITY

4

Black Infants are Four Times More Likely to Die than White Infants in

Westchester

4.4

2.8

12.7

2.7

0

2

4

6

8

10

12

14

Total White Black Hispanic

Deaths per 1,000 Live Births, 2004

Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf

55

HEALTH CARE

EQUITY

5

Black Children Are Three Times More Likely to Die Than

White Children in Westchester

1

0.7

2.7

0.9

0.2 0.10.3 0.20.2 0.2 0.3 0.2

0

0.5

1

1.5

2

2.5

3

Total White Black Hispanic

0-4yrs 5-9yrs 10-19yrs

Deaths per 1,000 Population, 2004


66

HEALTH CARE

EQUITY

6

Average Length of Stay for Pediatric

Hospitalization By Race, 2004

0

5

10

15

20

25

<1 1-2y 3-4y 5-6y 7-8y 9-10y 11-12y 13-14y 15-16y 17-18y 19-20y

White Black Hispanic


77

HEALTH CARE

EQUITY

7

Health Outcomes

• Life Expectancy

• Health Status

• Asthma Rates

• Diabetes Rates

Non-Medical

• Health Behaviors

• Living and Working Conditions

• Income

• Stress

Healthcare

• Acceptability

• Access

• Effectiveness

• Safety

• Financing

WHICH HEALTH DISPARITIES

88

HEALTH CARE

EQUITY

8

Health Outcomes

• Life Expectancy

• Health Status

• Asthma Rates

• Diabetes Rates

Non-Medical

• Health Behaviors

• Living and Working Conditions

• Income

• Stress

Healthcare

• Acceptability

• Access

• Effectiveness

• Safety

• Financing

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%

99

HEALTH CARE

EQUITY

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.

Asthma Diabetes Life

Expectancy

Life Stress +0.652

Per Capita

Health

Expenditure

-0.727 -0.814

Unemployment +0.836

Physicians +0.872

Income +0.821

Heavy Drinking -0.783

What Causes Disparities?

1010

HEALTH CARE

EQUITY

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

1111

HEALTH CARE

EQUITY

11


Environmental FactorsEconomic Factors

Cultural Factors

Community Factors




Patient Adherence



Dis

paritie

sWHAT CAUSES DISPARITIES?

1212

HEALTH CARE

EQUITY

12


Environmental FactorsEconomic Factors

Cultural Factors

Community Factors




Patient Adherence



Dis

paritie

sWHAT CAUSES DISPARITIES?

1313

HEALTH CARE

EQUITY

13

Is This About Race/Ethnicity or About Coverage?

1414

HEALTH CARE

EQUITY

14

Minority Children are More Likely to Lack Insurance Coverage

9 7 9

17

14

20

1413

0

10

20

30

40

Total White African American Hispanic

Uninsured All Year Uninsured Part Year

23

2023

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.

1515

HEALTH CARE

EQUITY

15

Racial Disparities in Clinical Quality

Occur Among the Insured

71%

50%

74%

54%63%

44%

64%

33%

0%

40%

80%

Breast CancerScreening

Diabetic EyeExam

Beta Blocker Use Mental IllnessFollow-Up

White African American

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

1616

HEALTH CARE

EQUITY

16

What Does it Really Take to Improve Care and

Reduce Health Disparities?

• Health care system comprised of purchasers, providers, regulators, researchers, educators, and others.

• Need a multifaceted approach that affects the different sectors of the health system

1717

HEALTH CARE

EQUITY

17

Health Care Coverage

1818

HEALTH CARE

EQUITY

18

State Children’s Health Insurance

Program (SCHIP)• Designed to provide coverage to low income

children not eligible for Medicaid

• Estimated that fewer than half of all eligible children are enrolled

• If every child who was eligible for either Medicaid or SCHIP was enrolled

– 6.7 million

– 76%

1919

HEALTH CARE

EQUITY

19

Expand SCHIP Eligibility

• Universal Health Care

• Uniform requirements for SCHIP eligibility

– from 133% to 400% FPL

– 39 states have caps of at least 200% *

• Raise SCHIP eligibility cap to 300% FPL

– 7.9 million

– 90.3% of uninsured children

*$41,300 for a family of four in 2007

2020

HEALTH CARE

EQUITY

20

Health Care Costs

$6 Billion Over 5 Years

$2.3 trillion in 2008

2121

HEALTH CARE

EQUITY

21

Monitor the Quality of CareStratified by Race/Ethnicity

2222

HEALTH CARE

EQUITY

22

Disparities in Healthcare and Quality of Care

• Measures of healthcare disparities are essentially quality measures.

• Disparities in health is not a marginal or special interest issue.

• There is a larger quality movement; use their tools, language and techniques.

• Calls upon quality movement to address quality for vulnerable patients.

2323

HEALTH CARE

EQUITY

23

COLLECTING RATE/ETHNICITY DATA:The First Step for Achieving Equity

• Barriers, is it legal?

• How to collect race/ethnicity data

• What categories?

• How long does it take?

• Who should ask?

• How do patients react?

What Do You Do With the Data?

2424

HEALTH CARE

EQUITY

24

Quality Improvement Reduces Disparities

30

40

50

60

70

80

90

100

1993 1994 1995 1996 1997 1998 1999 2000


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

Hem

odia

lysi

s D

ose

, %

2525

HEALTH CARE

EQUITY

25

Quality Improvement Could Maintain Disparities

30

40

50

60

70

80

90

100

1993 1994 1995 1996 1997 1998 1999 2000



46

36

87

77

Adequate

Hem

odia

lysi

s D

ose

, %

2626

HEALTH CARE

EQUITY

26

Quality Improvement Could Worsen Disparities

30

40

50

60

70

80

90

100

1993 1994 1995 1996 1997 1998 1999 2000



46

36

87

57

Adequate

Hem

odia

lysi

s D

ose

, %

2727

HEALTH CARE

EQUITY

27

Health Care Is Separateand Unequal

2828

HEALTH CARE

EQUITY

28

Percent of adults 18–64

69

77

75

11

9

13

9

6

10

12

5

3

4

6

5

4

62*

44* 21*

7

12

8

12*

1

15

Total

White

Asian American

African American

Hispanic

Doctor's office Community health center/Other public c linicsHospital outpatient/Other ERNo regular place of care

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.

2929

HEALTH CARE

EQUITY

29

1230

36

52

52

18

0%

20%

40%

60%

80%

100%

% Minority Patients %of Primary Care Physicians

High Medium Low

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

3030

HEALTH CARE

EQUITY

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

3131

HEALTH CARE

EQUITY

31

11

31

1813

15

36

25

1924

42

26

34

0

25

50

%Medicaid Inadequate Timewith Patients

Problems withReferrals toSpecialists

Problems GettingTimely Reports

Low Medium High

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

3232

HEALTH CARE

EQUITY

32

11.11

1.26

11.091.05

1.19

1

1.27

0

0.5

1

1.5

<15% Black

15-35% Black

>35% Black

NE

MW

S

outh

West

% Black Region NICU Volume

>40 Infants

<40

Infants

Od

ds

Rati

o

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

3333

HEALTH CARE

EQUITY

33

High Quality Care Promotes Equity

3434

HEALTH CARE

EQUITY

34

Total Percent by Race

IndicatorEstimated millions Percent White

African American Hispanic

Asian American

Regular doctoror source of care 142 80 85 79 57 84

Among those with a regular doctor or source of care . . .

Not difficult to contact provider over telephone

121 85 88 82 76 84

Not difficult to get care or medical advice after hours

92 65 65 69 60 66

Doctors’ office visits are always or often well organized and running on time

93 66 68 65 60 62

All four indicatorsof medical home 47 27 28 34 15 26

Source: Commonwealth Fund 2006 Health Care Quality Survey.

Hispanics Are Least Likely to Report Their Providers Have

Indicators of a Medical Home

3535

HEALTH CARE

EQUITY

35

55 57 56

46* 48*

0

25

50

75

100

Total White AfricanAmerican

Hispanic Asian

Percent of adults 18--64 reporting always getting care when they need it

*Compared to Whites, differences remain statistically significant after adjusting for incomeSource: 2006 Commonwealth Fund Health Care Quality Survey

Hispanics And Asians Are Less Likely to Report Always Getting

Medical Care When Needed

3636

HEALTH CARE

EQUITY

36

74767474

50525352

3431

4438

0

25

50

75

100


Medical Home Regular Source, no MH No Regular Source of Care/ER

Racial and Ethnic Differences in Getting Needed Medical Care Are EliminatedWhen 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

3737

HEALTH CARE

EQUITY

37

63 6659

55* 54*

0

25

50

75

100

Total White AfricanAmerican

Hispanic Asian

*Compared to Whites, differences remain statistically significant after adjusting for income or insuranceSource: 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

3838

HEALTH CARE

EQUITY

38

77747776

58556462

43444643

0

25

50

75

100


Medical Home Regular Source of Care, no MH No Regular Source of Care/ER

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

3939

HEALTH CARE

EQUITY

39

Health Care Providers

4040

HEALTH CARE

EQUITY

40

Cultural Competency Improves Quality of Care

43

7265

76

0

10

20

30

40

50

60

70

80

Excellent Good Fair Poor

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.

4141

HEALTH CARE

EQUITY

41

Promoting Cultural Competencyin Healthcare

Raise Awareness

Develop Measures of Processes and Outcomes

Set Standards for Practice

Incorporate into QI

4242

HEALTH CARE

EQUITY

42

Workforce Diversity

• Physicians of color more likely to serve in low-income and underserved communities and care for patients of color

• Better results when there is doctor-patient race and language concordance

• 25% of US population from underrepresented minority groups; only 11% of medical students are from these groups

4343

HEALTH CARE

EQUITY

43

People of Color Are Underrepresented in College, Medical School and

as Medical Faculty

19

4.6

11

32

0

10

20

30

40

18 year olds College Freshman First Year MedicalSchool

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.

4444

HEALTH CARE

EQUITY

44

What Does it Take to Eliminate Disparities in Care?

• Health Care Coverage

• Quality Improvement

• Train Health Care Providers

– Cultural Competency

– Workforce Diversity

• Disparities/Quality Oversight

4545

HEALTH CARE

EQUITY

45

An Aetna Foundation Priority:Racial and Ethnic Equity in

Health and Health Care

4646

HEALTH CARE

EQUITY

46

LOOKING AHEAD: The Foundation’s National Program Areas

• ObesityTo address the rising rate of obesity among U.S. adults and children

• Racial and ethnic health care equity To promote equity in health and health care for common chronic conditions and infant mortality

• Integrated health careTo advance high-quality health care by:

– Improving coordination and communications among – health care professionals – Creating informed and involved patients – Promoting cost-effective, affordable care

Beginning in 2010, we will focus our grant-making on issues that lead to meaningful improvements in health and the health care system:

4747

HEALTH CARE

EQUITY

47

CONTACT US

E-mail the Aetna Foundation:

[email protected]

Aetna Foundation website:www.AetnaFoundation.orgCall for Proposals Was

Released March 15, 2010

disparities in children's health

Health & Medicine