CMS’ Programs and Initiatives to Reduce Racial and Ethnic Disparities

CMS’ Programs and Initiatives
to Reduce Racial and Ethnic Disparities
Ellen O’Brien, Ph.D.
Research Associate Professor
Health Policy Institute, Georgetown University
June 28, 2005
AcademyHealth Annual Research Meeting
Boston, MA
Sources of Racial and Ethnic Disparities
in Medicare
Language gaps
Cultural barriers
Provider behavior/racial discrimination
What is CMS doing?
Research: documenting disparities and their causes
Beneficiary education and outreach: culturally and
linguistically appropriate materials and outreach strategies
(Horizons, SHIPs, QIOs, HBCUs, CMS regional office
Quality improvement: reducing disparities through
beneficiary- and provider-focused initiatives (QIOs, QAPI,
demonstration projects)
Reducing Disparities through Outreach
to Diverse Populations
– Spanish-language version of Medicare & You
– Language line service at 1-800-Medicare
Health Outreach Initiative Zeroing in On Needs (Horizons)
– Contractors produced descriptive reports on the populations,
health care needs, information needs, media outlets, etc.
• African Americans
• Hispanics/Latinos
• Asian Americans
– “Communications Toolkits” designed to improve the agency’s
ability to communicate with diverse groups
State Health Insurance Assistance Programs (SHIP) Grants
– Grants to selected SHIPs to do outreach to diverse populations
SHIP training
– Expanding enrollment of low income Medicare beneficiaries in
MSPs includes training module on cultural competency, Spanish
language translation
Disparities Reduction
as a Quality Improvement Activity
Medicare Quality Improvement Organizations (QIOs)
Medicare managed care plans: QAPI projects
Disparities Reduction as a Quality Improvement Activity
Medicare Quality Improvement Organizations (QIOs)
– New task added in 1999: reduce disparities for underserved
• dual eligibles
• racial/ethnic minorities
• rural beneficiaries
– Early efforts (1999-2002, 2002-2005)
• QIOs identify underserved populations
• Design intervention to reduce disparities
• Focus on use of preventive/screening services (flu shots,
mammography, diabetes testing)
• Focus on beneficiary outreach through community partnerships,
• To a lesser extent, focus on provider education
– Current efforts (2005-2008)
• Greater focus on physicians and office staff
• Increase providers’ understanding of cultural competency
• Increase compliance with the national Cultural and Linguistically
Appropriate Services (CLAS) standards (USDHHS/OMH)
Medicare QIOs, continued
Impact: Do QIOs reduce disparities?
– Perhaps. Interventions to reduce disparity in Black-white
mammography screening rate (8 projects)
• Baseline disparity (of 10- 11 percentage points)
• Disparity reduced in 6 of the 8 states
• Screening rate increased all groups, increased more for blacks
than whites, disparity reduced by 1 to 4 percentage points
– But, QIOs undertake efforts to increase mammography screening
for all populations
– Difficult to isolate impact of disparities initiatives
Opportunities for replication & expansion?
Disparities Reduction
as a Quality Improvement Activity
Medicare managed care plans: QAPI projects
Quality Assessment and Performance Improvement (QAPI)
Plans required to undertake a national QAPI project in 2003 to:
(1) reduce clinical health care disparities (CHCD project)
(demonstrate improvement in quality of care provided to a
racial/ethnic minority group)
Congestive Heart Failure
(2) enhance cultural and linguistic competence (CLAS project)
Improve language services (Identify LEP enrollees, Inform
enrollees of right to language services, provider directory,
Organizational changes to improve cultural competence
(recruit staff, providers who reflect racial/ethnic
composition of enrolled population)
QAPI, continued
– Are plans able to reduce clinical disparities? enhance cultural and
linguistic competence? What works?
– No data available on plans’ interventions or the impact of their
QAPI projects
– Plans report on 2003 projects by October 1, 2005
– 3 QIOs do primary review of PI; CMS approves
Opportunities for replication/expansion?
– CMS does not release plan-specific information on what
works/does not work.
– Future technical assistance could build on what was learned as a
result of 2003 QAPI national project
– But, national QAPI requirements for MA plans eliminated in 2005
and beyond
Demonstration Projects
Cancer Prevention and Treatment Demonstration
Chronic Care Improvement Projects
The Cancer Prevention and Treatment
Improve early detection and treatment for cancer (reduce disparities)
Focus on screening, diagnosis, and treatment
American Indians (including Alaskan Native, Eskimo and Aleutian)
Asian Americans
Pacific Islanders
Breast cancer
Cervical cancer
Colorectal cancer
Prostate cancer
Lung cancer (treatment for patients with diagnosis)
Interventions? helping racially and ethnically diverse beneficiaries
“navigate” the healthcare system; patient tracking and decision
support tools; community health workers, etc.
The Cancer Prevention and Treatment
– Proposals were due March 2005
– 29 received – University health systems, medical association, hospital
systems, community-based organizations, large provider group
– CMS in process of selecting sites
– Legislation called for at least 9 sites, but budgets were high, funds may
not accommodate 9 sites or a 3-5 year demo
– Demo expected to start late fall 2005
– Independent evaluation
A Preliminary Assessment of CMS’ Activities
Reducing racial and ethnic disparities needs to be a higher priority
Focus on beneficiaries important, but greater attention needed to
changing physician behavior.
Activities have been limited in scope, some are important first steps.
Progress needs to be monitored; difficult to determine what’s
Improving care and outcomes for diverse populations matters, focus
on disparities reduction should be maintained.
CMS can go well beyond what it is currently doing (Tim Jost).
Prepared for the National Academy of Social Insurance, Study Panel on
Sharpening Medicare’s Tools to Reduce Racial and Ethnic Disparities.
Paper Available at:
Thanks to Bruce Vladeck for inviting me to write the paper, and to NASI and
the Joint Center for Political and Economic Studies for funding.
Thanks to the many individuals inside and outside of CMS who gave their
valuable time to describe these programs and their impact.
Thanks to the Study Panel, and especially to Dan Bourke, Rose CrumJohnson, Nilda Chong, and June Eichner for their helpful comments.
Please send comments, criticisms, questions to [email protected]