Racial/Ethnic Disparities and Health Policy

A View from the Field

Joseph R. Betancourt, M.D., M.P.H.

Director, The Disparities Solutions CenterSenior Scientist, Institute for Health Policy

Director for Multicultural Education, Massachusetts General Hospital

Assistant Professor of Medicine, Harvard Medical School

Outline

The US Healthcare System

Quality, Racial/Ethnic Disparities, and Key Clinical Lessons

Health Care Reform: Implications for Disparities

A View from the Field

The US Healthcare SystemBackground and Context

Patchwork system of Health Insurance– Employer-Based Health Insurance Dominant

– Government ProgramsMedicaid: Low-income women and childrenSCHIP: Low to moderate income childrenMedicare: Universal Access > 65, disabled, HDSpecial Populations (VA, DoD, IHS)

Lack of Insurance a Major Issue– 46-50 Million Americans Uninsured

– Minorities, immigrants over-represented among theseLatinos 13% of population, 25% of uninsured

The US Healthcare SystemBackground and Context

Healthcare Expenditures Increasing

– Technology, Pharma, End-of-Life, Regional Variation

– Cost as part of GDP no longer sustainable

– Expenditures don’t translate to leading indicators

Infant Mortality as an example

– Health care reform on horizon; in place in MA

California budget issues strain services

– Issues magnified in state with high uninsured, immigrants

– Health and human services particularly affected

The US Healthcare SystemBackground and Context

Quality of Health Care Suboptimal– Patients receive recommended services

only 54% of the time

– New focus on improving quality

Racial/Ethnic Disparities in Health Care– Minorities receive lower quality health care

even when controlling for SES, insurance

status, comorbidities, stage of presentation

– New focus on achieving equity

Diabetes-Related Death Rate, 2006

Deaths per 100,000 population

22.8

50.1

33.6

50.3

18.4

0

10

20

30

40

50

WHITE AFRICANAMERICAN

HISPANIC AI/AN ASIAN/PI

Racial/Ethnic Disparities inHealth Care

In patients with insurance…– Disparities based on race for:

Influenza vaccination (Gornick et al.)

Lung Ca Surgery (Bach et al.)

Renal Transplantation (Ayanian et al.)

Treatment of chest pain, cardiac catheterization, angioplasty, bypass (Harris et al, Ayanian et al., Peterson et al., Johson et al.)

Referral to cardiology specialist care (Schulman et al.)

Treatment of HIV/AIDS (Shapiro et al.)

Pain management (Todd et al.)

Disparities in Health Care

Key Clinical Lessons from Unequal Treatment

Minorities Face Greater Difficulty in Communicating with Physicians

19%16%

23%

33%

27%

0%

20%

40%

Total White AfricanAmerican

Hispanic AsianAmerican

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*

Clinical Decisionmaking and Stereotyping

Automatic aspects; groupindividual “Cognitive Misers”cognitive shortcuts to

save resources; principle of “least effort” Primal->race, gender, age Activated most when:

– Stressed– Under time constraints– Multitasking

The Patient Perspective: Unequal Treatment

Kaiser Family Foundation Survey, 2000

58

36

65

35

22

15

0 20 40 60 80

Fu

ture

un

fair

Tx

bas

ed o

nra

ce/e

thn

icit

y

Pas

t u

nfa

ir T

xb

ased

on

race

/eth

nic

ity

Whites

Blacks

Latinos

Percent

Quality Health Care

Health care should be

– Safe

– Effective

– Patient-centered

– Timely

– Efficient

– Equitable

Linking Disparities to Quality Safe

– Minorities have more medical errors with greater clinical consequences

Effective– Minorities received less evidence-based care (diabetes)

Patient-centered– Minorities less likely to provide truly informed consent

Timely– Minorities more likely to wait for same procedure (transplant)

Efficient– More test ordering in ED for minorities due to poor

communication

Also– Minorities have more CHF readmissions, ACS admissions, and

longer length of stay for the same condition

IOM’s Unequal Treatmentwww.nap.edu

Recommendations

Increase awareness of existence of disparities

Address systems of care

– Support race/ethnicity data collection, quality improvement, evidence-based

guidelines, multidisciplinary teams, community outreach

– Improve workforce diversity

– Facilitate interpretation services

Provider education

– Health Disparities, Cultural Competence, Clinical Decisionmaking

Patient education (navigation, activation)

Research

– Promising strategies, Barriers to eliminating disparities

Key Issues

Addressing Disparities in the Context of Quality and Reform

Need for InnovationKey Challenges to Quality and Equity

Primary Care and Nursing Shortage– Specialty shortage in certain areas

Productivity requirements, short medical visits– Little time for review, education, counseling

Reimbursement for procedures, episodes– Little incentive for coordinated care

Defensive and “Patient Satisfaction” Medicine– Procedures, Prescriptions

Greater call for documentation– Pros and cons of the EMR

New efforts in P4P– Metrics, measures, and impact on disparities

Need for InnovationHealth Care Reform Principles

Increase Access– Employer, Individual Mandate, Elimination of pre-existing conditions– Competitive insurance products via new market; Gov’t support

Public Option/Co-Op’s?

Improve Quality– Effective care via evidenced-based practice

Disease Management, new efforts in wellness– Health Information Technology

PHR, EMR, CDM and Decision Support

Bending the Cost Curve– Payment Reform

Provider changes, P4P, Medical Home, Accountable Organizations– Savings from improving quality

Decreasing redundancy, inappropriate utilization

A View from the Field

Current Context and Strategies to Address Racial/Ethnic Disparities

in Health Care

Accreditation, Quality Measures, Employer Leverage NCQA

– New efforts in disparities

– Measures released in 2009

Joint Commission– New project on culture, health and disparities

– New disparities/cultural competence accreditation standards 2007, completed

public comment, plan for release in 2010-11

National Quality Forum– Developed cultural competence quality measures in 2009

National Business Group on Health– Developed major effort to educate employers about disparities, including making

the business case; brief released in 2009

A View from the FieldBuilding Equitable Systems and Incentives

Race/ethnicity data collection

Quality improvement plans and incentives to achieve goals (P4P)

Increase Capacity of Health Care Providers

Foster cultural competence of health care providers

Empower Patients

Support navigation and educational activities

20/80 Rule: NHDR

Asthma, Diabetes, CVD, CRC Screen, Mental Health

Identifying and Benchmarking Disparities:The Example of MGH

Medical Policy– All QI stratified by race/ethnicity

Unit-Based Staff Quality Rounds– Exploring potential disparities-causing events

Patient Satisfaction– Stratify results by r/e and added questions about

respect for culture/race/religion

Nat’l Hosp Qual Measures, HEDIS Measures– Stratifying results by race/ethnicity

Disparities Dashboard– Report routinely to leadership

We are including the Core Measures for Heart Attack, Heart Failure and Pneumonia.

Need for Innovation Models at Massachusetts General Hospital

Health Coaches– Based at health care delivery site

– Assist with chronic disease management (ex. Diabetes)

Health Care Navigators– Based at health care delivery site

– Assist with health promotion (cancer screening) and disease prevention (cancer progression)

Community Health Workers– Based in community, visit home

– Assist with chronic disease management (ex. Asthma)

The MGH Chelsea Diabetes Program

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

MGH Chelsea Diabetes Program: A quality improvement / disparities

reduction program with 3 primary components:

• Telephone outreach to increase rate of HbA1c testing

• Individual coaching to address patients’ needs and concerns regarding

diabetes self-management to improve HbA1c (1500 visits, 400 routine

patients seen)

• Group education meeting ADA requirements (150 patients)

Diabetes Control Improving for All: Gap between Whites and Latinos Closing

24% 24%

20%

37%

34%

29%

0%

10%

20%

30%

40%

50%

2005 2006 2007

Year

% o

f P

atie

nts

wit

h P

oo

rly

Co

ntr

olle

d D

iab

etes

(H

bA

1c

> 8

) Whites

Latinos

* 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

Need for InnovationHealth Care Reform Disparities Provisions and Analysis

Increase Access– Will help address disparities

Improve Quality– Specific disparities-related provisions and resources for:

Race/Ethnicity Data Collection Disease Management Health Information Technology Workforce Diversity and Cultural Competence Training

Bending the Cost Curve– Payment Reform

Provider changes, Medical Home, Accountable Organizations should help address disparities; ? P4P

Funding for interpreter services

Implications for Small PracticesWhat can you do?

Monitor Quality by Particular Characteristics– Collect race/ethnicity data

– Assess via chart audit, or through EMR

Partner with other organizations/Develop interventions– Community-Based Organizations

CHW’s

– Major Associations (ADA, AHA) Coaches, Promotoras, Navigators

– Private Industry/Pharma Key educational resources

Keep up-to-date on services, resources Continued policy and advocacy

Summary

There is a significant body of evidence that demonstrates the

challenges of moving forward with our health care system

Health care reform impending, implications for quality and

disparities are clear

As providers we must stay engaged in the debate, create

high-quality systems, and use positions of advocacy