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
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Sources of Racial and Ethnic Disparities
in Medicare
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Poverty
•
Language gaps
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Cultural barriers
•
Provider behavior/racial discrimination
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What is CMS doing?
•
Research: documenting disparities and their causes
(HCBUs, HSIs)
•
Beneficiary education and outreach: culturally and
linguistically appropriate materials and outreach strategies
(Horizons, SHIPs, QIOs, HBCUs, CMS regional office
initiatives)
•
Quality improvement: reducing disparities through
beneficiary- and provider-focused initiatives (QIOs, QAPI,
demonstration projects)
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Reducing Disparities through Outreach
to Diverse Populations
•
Translation/interpretation
– 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
4
Disparities Reduction
as a Quality Improvement Activity
•
Medicare Quality Improvement Organizations (QIOs)
•
Medicare managed care plans: QAPI projects
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Disparities Reduction as a Quality Improvement Activity
•
Medicare Quality Improvement Organizations (QIOs)
– New task added in 1999: reduce disparities for underserved
populations
• 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)
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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?
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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)
•
Pneumonia
•
Mammography
•
Diabetes
•
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,
interpreters)
•
Organizational changes to improve cultural competence
(recruit staff, providers who reflect racial/ethnic
composition of enrolled population)
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QAPI, continued
•
Impact
– 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
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Demonstration Projects
•
Cancer Prevention and Treatment Demonstration
•
Chronic Care Improvement Projects
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The Cancer Prevention and Treatment
Demonstration
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Improve early detection and treatment for cancer (reduce disparities)
–
–
–
–
–
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Focus on screening, diagnosis, and treatment
–
–
–
–
–
•
American Indians (including Alaskan Native, Eskimo and Aleutian)
Asian Americans
Blacks
Hispanics/Latinos
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.
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The Cancer Prevention and Treatment
Demonstration
•
Status
– Proposals were due March 2005
– 29 received – University health systems, medical association, hospital
systems, community-based organizations, large provider group
practices
– 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
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A Preliminary Assessment of CMS’ Activities
•
Reducing racial and ethnic disparities needs to be a higher priority
activity.
•
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
working.
•
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).
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Acknowledgments
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Prepared for the National Academy of Social Insurance, Study Panel on
Sharpening Medicare’s Tools to Reduce Racial and Ethnic Disparities.
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Paper Available at:
www.nasi.org/publications2763/publications_show.htm?doc_id=278645
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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.
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Thanks to the many individuals inside and outside of CMS who gave their
valuable time to describe these programs and their impact.
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Thanks to the Study Panel, and especially to Dan Bourke, Rose CrumJohnson, Nilda Chong, and June Eichner for their helpful comments.
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Please send comments, criticisms, questions to obriene@georgetown.edu
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