Policies to Reduce Disparities
in Child Health Care
Anne Beal
Senior Program Officer
The Commonwealth Fund
Bronx CREED, AECOM
February 16, 2007
Minorities Are the Majority
in New York City
2 or more races
Other races <1%
Asian 10%
White 35%
Hispanic 27%
Black 25%
Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.
Blacks and Hispanics are
the Poorest in NYC
<$25,000
$25,000-49,000
>$50,000
60
50
50
46
42
42
40
30
28
27
30
23
32
28
26
26
20
10
0
White
Black
Hispanic
Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.
Asian
Blacks and Hispanics Face
Inferior Housing Conditions
<$25,000
45
40
35
30
25
20
15
10
5
0
$25,000-49,999
>$50,000
Percent of adults reporting mouse
and rat sightings in their home
43
38
35
33
27
27
18
10
White
10
Black
Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.
Hispanic
Blacks and Hispanics are in
Poorer Health in NYC
<$25,000
40
30
$25,000-49,000
>$50,000
38
Percent of adults reporting their
health as “fair” or “poor”
28
26
25
20
14
12
13
13
8
10
0
White
Black
Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.
Hispanic
Which Health Disparities?
Non-Medical
•Health Behaviors
•Living and Working
Conditions
•Income
•Stress
Health Outcomes
•Life Expectancy
•Health Status
Healthcare
•Acceptability
•Access
•Effectiveness
•Safety
•Financing
•Asthma Rates
•Diabetes Rates
Which Health Disparities?
Non-Medical
•Health Behaviors
•Living and Working
Conditions
40%-67%
•Income
•Stress
Health Outcomes
•Life Expectancy
•Health Status
Healthcare
•Asthma Rates
•Acceptability
•Access
•Diabetes Rates
44%-57%
•Effectiveness
•Safety
•Financing
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
Life Stress
+0.652
Per Capita
Health
Expenditure
-0.727
Unemployment
Diabetes
Life
Expectancy
-0.814
+0.836
Physicians
+0.872
Income
+0.821
Heavy
Drinking
-0.783
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.
Focus on Healthcare Quality and
Disparities
• Impacts health status
• Functions within a single “system”
• Best way to leverage limited funds
• Opportunity to build on general quality
efforts
Federal Initiatives to Address
Disparities
Minority Health and Health Disparities
Research and Education Act 2000
• Written by Senators Edward M. Kennedy
and Bill Frist
• Established National Center on Minority
Health and Health Disparities at NIH
• Funded Excellence Centers to Eliminate
Ethnic/Racial Disparities (EXCEED)
Department of Health and Human
Services Initiatives
• Closing the Health Gap Campaign
– Youth media campaign to promote physical
activity in children 9-13
• Healthy People 2010 Objectives
– Priority areas include 2 child health areas:
immunizations and infant mortality
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
Knowledge
Disparities in Disparities
• IOM literature
review: only 5 of
103 published
studies address
disparities in
children
Disparities in Disparities
• NHDR found
examination of child
health disparities
limited by lack of data
– Small sample sizes
– Few child-specific
measures of effective
clinical care
Uninsured Top Priority for Congress
According to Health Care Opinion Leaders
“How important do you think the following health care issues
are for Congress to address in the next five years?”
Top 10 issues: Percent responding “absolutely essential” or “very important”
Expand coverage for the uninsured
1
Enact reforms to moderate rising health care costs
2
81%
Reform Medicare to ensure its long-run solvency
3
80%
Increase use of IT to improve quality, safety of care
3
80%
Expand SCHIP to reach all uninsured children
5
76%
Ensure families don't pay excessive out-of-pocket
costs in relation to income
6
75%
Address shortage of trained health care professionals
7
Control the rising cost of prescription drugs
8
Reform Medicare payment to reward performance on
quality, efficiency
9
64%
Reduce racial/ethnic disparities in care
9
64%
Note: Based on a list of 17 issues.
Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan 2007.
88%
70%
66%
Uninsured Top Priority for Congress
According to Health Care Opinion Leaders
“How important do you think the following health care issues
are for Congress to address in the next five years?”
Top 10 issues: Percent responding “absolutely essential” or “very important”
Expand coverage for the uninsured
1
Enact reforms to moderate rising health care costs
2
Reform Medicare to ensure its long-run solvency
3
80%
Increase use of IT to improve quality, safety of care
3
80%
Expand SCHIP to reach all uninsured children
5
76%
Ensure families don't pay excessive out-of-pocket
costs in relation to income
6
75%
Address shortage of trained health care professionals
7
Control the rising cost of prescription drugs
8
Reform Medicare payment to reward performance on
quality, efficiency
9
64%
Reduce racial/ethnic disparities in care
9
64%
Note: Based on a list of 17 issues.
Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan 2007.
88%
81%
70%
66%
Health Care Coverage
Minority Children are More Likely
to Lack Insurance Coverage
Percent of Children Ages 0-18 Uninsured All Year
US Uninsured
40
NYS Uninsured
30
17
20
10
7
7
9
12
11
0
White
African American
Hispanic
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.
http://www.childrenshealthcampaign.org/assets/pdf/Uninsured-Minority-Kids-at-Risk.pdf
Minority Children are More Likely
to Lack Insurance Coverage
Percent of Children Ages 0-18 Uninsured All or Part Year, 2000
Uninsured All Year
Uninsured Part Year
40
30
23
20
20
14
13
23
37
20
14
10
17
9
7
9
0
Total
White
African American
Hispanic
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.
State Children’s Health
Insurance Program (SCHIP)
• Designed to provide coverage to low
income children not eligible for
Medicaid
• Estimated that fewer that half of all
eligible children are enrolled
• If every child who was eligible for
either Medicaid or SCHIP was
enrolled
– 6.7 million
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
Quality Improvement
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.
Disparities Are Due to WHO You Are and
WHERE You Go
% Black
1.5
Region
NICU
Volume
1.27
1.26
1.19
1.11
1
Odds Ratio
1
1.09 1.05
1
1
0.5
0
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.
Children of Color Are More Likely to Have
Public Insurance
Percent of Children Ages 0-18 With Public Only Insurance, 2002
60
46.9
38.3
40
20
18.4
0
White
African American
Hispanic
Source: Rhoades J, Cohen J. Statistical Brief #28: Health Insurance Status of Children in America: 1996-2002.
November 2003. AHRQ. http://www.meps.ahrq.gov/papers/st28/stat28.htm
Medicaid Managed Care Plans Do
Not Perform as Well as
Commercial Plans
Commercial
80
70
60
Medicaid Plan
69
54
50
40
53
31
30
20
10
0
Childhood Immunization Rates
Inadequate # of well-child visits
(first 15 months)
Source: Thompson JW et al. Quality of Care for Children in Commercial and Medicaid Managed Care. Journal
of the American Medical Association 290, no. 11 (2003):1486-1493.
Children of Color Get Most of Their Health
Care in Private MD Offices
Usual Place of Health Care for Children 0-18 With a Source of Care
Private MD
Hispanic
African American
White, NonHispanic
Total, 0-18
Clinic
Hospital Outpatient
64%
32%
68%
2%
27%
4%
84%
78%
15% 1%
20%
Source: Bloom B, Cohen RA, Vickerie JL, Wondimu EA. Summary health statistics for U.S. children: National
Health Interview Survey, 2001. National Center for Health Statistics. Vital Health Stat 10(216). 2003.
1%
Monitoring Disparities in
Quality
• Child health care quality measures
are not designed for measuring
disparities
– Collect data on patients’ race and
ethnicity;
– Stratify reporting of quality measures by
race and ethnicity
• Apply QI techniques
– P4P, Registries, Report Cards, Case
Quality Improvement Reduces
Disparities
Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000
White
Adequate Hemodialysis Dose, %
100
African American
90
87
80
84
70
60
50
46
40
30
36
1993
1994
1995
1996
1997
Source: Adapted from Sehgal: JAMA, Volume 289(8). February 26, 2003. 996-1000.
1998
1999
2000
Quality Improvement Could Maintain
Disparities
Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000
White
Adequate Hemodialysis Dose, %
100
African American
87
90
80
70
77
60
50
46
40
30
36
1993
1994
1995
1996
1997
1998
1999
2000
Quality Improvement Could Worsen
Disparities
Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000
White
Adequate Hemodialysis Dose, %
100
African American
87
90
80
70
60
50
46
57
40
30
36
1993
1994
1995
1996
1997
1998
1999
2000
Health Care Providers
Cultural Competency Improves
Quality of Care
Preventive medication underuse among children with persistent asthma
80
76
72
65
70
60
50
43
40
30
20
10
0
Excellent
Good
Fair
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.
Poor
Current Practices and Policies
Liaison Committee on Medical
Education
• requires all medical schools to
include cultural competency training
in curricula
Accreditation Council for Graduate
Medical Education
• includes responsiveness to diverse
Promoting Cultural Competency
in Healthcare
Raise Awareness
Set Standards for Practice
Develop Measures of Processes and Outcomes
Incorporate into QI
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 doctorpatient race and language
concordance
• 25% of US population from
underrepresented minority groups;
only 11% of medical students are
People of Color Are Underrepresented in
College, Medical School and as Medical
Faculty
Percent of Students from Underrepresented Groups
40
32
30
19
20
11
10
4.6
0
18 year olds
College Freshman
First Year Medical
School
Medical Faculty
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.
Health and Education
Empowerment Zones
High School Dropout Rate
Asthma Hospitalizations, 5-14 Years
Late or No Prenatal Care
What Does it Take to Eliminate
Disparities?
• Knowledge
• Health Care Coverage
• Quality Improvement
• Train Health Care Providers
– Cultural Competency
– Workforce Diversity
• Community Action
• Disparities Oversight Council
Visit the Fund at
www.cmwf.org