Efforts to Reduce Disparities in Care for Medicare
Beneficiaries
Peter B. Bach, MD, MAPP
Senior Adviser, Office of the Administrator
Centers for Medicare & Medicaid Services
Today
• The Agency philosophy regarding health disparities
• Programmatic initiatives in health disparities
• Specific health disparities initiatives
• Trying to move forward– What should we do?
– What can we do?
Agency Philosophy
• All quality initiatives should be evaluated in light of their potential impact on the health of minority populations– Will adequate groups be included in
‘demonstrations’?
– Will methodology or risk selection adversely affect minorities?
– Are appropriate suites of measures being chosen to drive improvements in minority health?
Agency Philosophy cont’d
• Specific quality initiatives should focus on directly addressing identified mechanisms
• Should be assessed based on impact on patients, including satisfaction with care and outcomes
Mechanisms underlying disparities
• Communication and comprehension barriers
• Differences in access
• Differences in coverage
• To better define mechanisms:– Projects, interventions, demonstrations and
research
Communication
• National Medicare Education Program (NMEP) – 1997 BBA
• Includes:– 1-800-Medicare
– www.medicare.gov
– Medicare & You Handbook
– HORIZONS
– Other
HORIZONS (Health Outreach Initiative
Zeroing in On Needs)• Formed to identify strategies to reach
“hard to reach” populations• Toolkits created for outreach to:
– African Americans; Asian American/Pacific Islander; Hispanic American
• Include: – Handbooks, print brochures, media scripts
REACH
• Regional Education About Choices in Health Care
• Implemented by CMS Regional Offices to increase access to Medicare information
• Targets:
-Low Income -Location
-Language-Literacy
-Culture
State Health Insurance Assistance Programs (SHIP’s)
• Funded by CMS to provide counseling to Medicare beneficiaries– Specifically about issues related to Medigap and drug coverage
• Counselors community based, often volunteers• Present in all 50 states + D.C.• Mandated to target underserved populations (usually
defined by income)• CMS has developed training materials (English and
Spanish) in counseling and cultural competency
Access
• Specific concerns about lack of proper healthcare facilities locally available to minority populations
• Health Care Infrastructure Improvement Program – Sec 1016 of MMA– Large loans to facilities to build-out cancer care
infrastructure– Specifically targeted at geographic regions where there
are large populations of Native Americans• Tremendous amount of infrastructure work
focused on geographic availability of drug benefit and DME
Coverage differences
• Not all beneficiaries have the same coverage– Part B coverage requires co-pays and has a
deductible• Minorities more likely to have Medicaid
– 32% of blacks; 9% of whites
• Minorities more likely to have no coverage– 20% of blacks, 14% of whites
Coverage differences
• Important preventive services no longer need co-pay and do not affect deductible– Vaccines – influenza, pneumococcal, Hep B
– Cancer screening – mammograms, PSA test, FOBT
• Change in Part B drug reimbursement to ASP– Effect should be that physicians payments more similar
when treating patients with Medicare and Medicaid than previously
Specific programs and interventions
Utilization and Access to Care
• Health Disparities: Measuring Health Care Use and Access for Racial/Ethnic Populations– Analyzes health care access trends
– Assesses validity of race/ethnicity data in the Medicare enrollment database
READII
• Racial and Ethnic Adult Disparities in Immunization Initiative– CMS collaborates with CDC to improve flu and
pneumococcal immunization rates
• Focuses on African Americans and Hispanics
• Five locations:– Chicago, IL– Bexar County (San Antonio vicinity), Texas– Milwaukee, WI– Monroe County (Rochester vicinity), NY– Selected Counties, rural MS
QIOs
• Quality Improvement Organizations
• Established by legislation in 1982 to improve quality of care
• Present in all 50 states and U.S. territories
• Undertake special efforts in health care, including specific diseasesand disparities inminority populations
• QIO’s are “on the ground”, working with providers, beneficiaries, and networks
QIO Disparity Projects
• 1999-2002 51 projects• 2002-2005 52 projects• Include global measures on diabetes,
mammography screening, immunization, and heart failure
• Two tasks in next scope– Work with providers who treat underserved to use IT
more effectively (DOQ-IT)– Promote provider and practice system changes to
achieve CLAS (culture and language) standards and cultural competency
Medicare Advantage Plans
• Ensure that all services are accessible to all
• QIO’s charged with improving care in these plans
• The QAPI project requires plans also to improve cultural competence, either as manifest by reducing a clinical health disparity or by developing cultural initiatives
HBCU Grant Program
• Historically Black Colleges and Universities Health Services Research Grant Program
• Small applied projects awarded to:– Remove barriers and improve health– Increase efficient utilization– Improve quality– Reduce health care costs– Improve HIV and AIDS outcomes
CMS Demonstrations
• Physician Group Practice Demonstration
• Medicare Health Support (CCIP)• Cancer prevention and treatment
Physician Group Practice Demonstration
• Awardees are 10 large physician group practices
• Focuses on the quality of preventive care and ultimately on the outcomes of beneficiaries treated by the groups
• Incentives for practices – better efficiency and outcomes will result in bonus payments
Medicare Health Support
• Formerly the Chronic Care Improvement Program (CCIP)• Beneficiaries with specific conditions – congestive heart
failure and diabetes – who reside in target regions• Regions (10) chosen for high prevalence
– Chicago, DC, Georgia, Mississippi, Brooklyn/Queens
• Randomized study where enrollees can receive additional care management
• Objective is to enhance existing physician-patient relationships
Cancer Screening & Treatment
• Cancer Prevention and Treatment Demonstration for Ethnic and Racial Minorities
• Defined racial and ethnic minority groups
• Sites (rural and inner city) will facilitate cancer screening, diagnosis and treatment
• Charged with funding 9 sites
Screening and Treatment
• Randomized designs
• Invited participants: Care management organizations, health insurers, group practices, academic health centers, minority serving institutions
• Two promising strategies addressed
– Risk assessment assistance
– Patient navigation/community health workers
Cancer Screening Demo Status
• Solicitation was published in the Federal Register on 12/23/04
• Proposals were due 3/23/05
• Award is expected mid-2005
• Full-scale implementation in Fall 2005
Other Initiatives
• HHS “Closing the Health Gap” campaign– Take a Loved One to the Doctor Day initiative
– Broadcasts on ABC Radio Networks
• Celebra La Vida Con Salud initiative– Celebrate a Healthy Life
Summary
In addressing this problem, CMS:
• Recognizes the magnitude of the problem
• Recognizes it has a special responsibility to address the problem
• Leverages all Agency resources
• Seeks ideas, suggestions, and support from ALL!
