December 2006

Grant Results

SUMMARY

From 2001 to 2002, researchers with the National Academy for State Health Policy at the Center for Health Policy Development examined the ways in which states use their power to purchase and regulate health care services to reduce disparities in health due to racial and ethnic differences.

Key Findings
A 2002 report from the academy — State Purchasing and Regulation of Health Care Services: A Snapshot of Strategies to Reduce Racial and Ethnic Health Disparities — lists these key findings:

  • State purchasers and regulators of health care services have at their disposal a number of tools to address racial and ethnic disparities; the most common of these is translation and interpreter services.
  • State strategies vary depending on the needs of minority populations, and the state's capacity to address them.
  • The issue of racial disparities can slip through the cracks if states fail to focus on it.
  • Many states lack performance measures and data to focus their strategies.
  • States may have opportunities to improve the effectiveness of health care purchasing and regulatory strategies by increased collaboration.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $93,305.

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THE PROBLEM

Despite improvement in the nation's overall health, racial and ethnic minority groups still experience a disproportionately worse health status and access to health care, and report lower satisfaction with their care than white Americans. States can leverage their extensive purchasing and regulatory powers to improve the care delivered to minorities. For example, states have worked with the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) to assure that Medicaid managed care plans deliver culturally competent care. Some state offices of minority health have been charged with working on reducing disparities; however, many of these offices are small and poorly funded.

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THE PROJECT

Research staff at the National Academy for State Health Policy:

  • Conducted a literature search to identify existing research and findings on state strategies to address minority health disparities.
  • Surveyed 35 state offices of minority health to identify the strategies used by states as regulators and purchasers to reduce health disparities and to determine the role of offices of minority health in these initiatives. Twenty-eight minority health offices completed the survey for a response rate of 80 percent.
  • E-mailed a short survey to Medicaid programs, State Children's Health Insurance Programs (SCHIPs), and state employee benefits and insurance departments in all 50 states to obtain information on what purchasing and regulatory strategies they use to address racial and ethnic health disparities. Nine states responded.
  • Conducted telephone interviews with state agency representatives in California, Delaware, Massachusetts, New Jersey, New York, Texas, Washington, and Wisconsin — the states the researchers identified as having promising or established initiatives for reducing minority health disparities. Those interviewed included representatives of Medicaid, SCHIPs, state employee benefits departments, insurance departments and offices of minority health.

In February 2002, the academy hosted a one-day summit with representatives of state public health offices, offices of minority health, Medicaid, SCHIPs, state insurance departments and state employee benefits programs. Fourteen state officials from 12 states were in attendance, 10 from state regulatory or purchasing organizations and the other four from offices of minority health. Participants discussed survey and interview findings and identified the most promising and effective strategies.

An expert advisory group guided the academy staff's efforts. (See the Appendix for a list of members.)

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FINDINGS

The Academy's April 2002 report (see the Bibliography for details), highlights these key findings:

  • State purchasers and regulators of health care services have at their disposal a number of tools to address racial and ethnic disparities. The most common of these is translation and interpreter services. But increasingly, states can use their health care purchasing and regulatory authority to address cultural barriers to care, including such strategies as consumer outreach and education programs, cultural competency requirements for health programs and managed care organizations' provider networks, consumer advocacy efforts and culturally relevant quality improvement and disease-management initiatives.
  • State strategies vary depending on the needs of minority populations — and the state's capacity to address them. In states that have had a dramatic increase in minority populations, for example, cultural and linguistic services have become essential components of quality care rather than an "extra."
  • The issue of racial disparities can slip through the cracks if states fail to focus on it. To achieve results, state initiatives need to be strategic and focused, with clear goals, benchmarks and coordination of effort.
  • Many states lack performance measures and data to focus their strategies. State health care purchasers typically do not analyze service utilization, quality improvement and patient satisfaction by race and ethnicity. As a result, they lack the data to help them to identify risk factors by race and ethnicity and develop culturally appropriate interventions.
  • States may have opportunities to improve the effectiveness of health care purchasing and regulatory strategies by increased collaboration. Many states have not coordinated the efforts of agencies, so staff have few opportunities to share concerns, information or ideas about addressing disparities and may be unaware of each other's roles and mutual interests. States also need to partner with providers, health plans and communities in order to address rapidly changing community needs.
  • States address health disparities through both narrowly focused strategies and more broad-based efforts. States themselves may not identify many programs that address minority health disparities as such. For example, a state program may label a sickle cell anemia or diabetes management program that will benefit a minority population as a disease management effort rather than a minority health initiative. (See Lessons Learned)
  • State officials in leadership positions can help state health care purchasing and regulatory agencies use their leverage to address racial and ethnic health disparities. A state leader can choose areas with clearly identified problems and articulate opportunities for change.

Communications

The National Academy for State Health Policy published a report on the study, State Purchasing and Regulation of Health Care Services: A Snapshot of Strategies to Reduce Racial and Ethnic Health Disparities, which was disseminated to nearly 400 state health policy-makers, including offices of minority health, Medicaid directors, SCHIP directors, insurance commissioners and state employee health benefits purchasing directors. Interested persons can view an abstract of the report at the academy Web site or order a full copy for $30.

In addition, the National Academy of State Health Policy Annual Conferences in 2001, 2002 and 2003 included presentations on findings from the study. A lead investigator presented the study findings at the American Public Health annual meeting in 2002.

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LESSONS LEARNED

The lead researchers, Rosenthal and Kaye, identified two lessons for the field:

  1. Several different survey methods may be necessary to reach a variety of audiences. Researchers used e-mail, mail and phone interviews to gather information from a variety of agencies within state government. They found that some state agencies had programs that addressed racial and ethnic health disparities but were not necessarily identified as such. As a result, it became evident that it was necessary to use a variety of methods and to survey a variety of agencies to get a more comprehensive picture of state strategies to reduce racial and ethnic health disparities. It also assisted in identifying areas for follow-up interviews. Recognizing that some agencies experienced survey fatigue, it helped to gather cursory information and follow up with those that looked most promising.
  2. State agencies, even within one state, are not necessarily aware of each other's initiatives and the potential to collaborate to meet similar goals. Researchers gathered the bulk of their information from state minority health offices. Subsequent telephone interviews and the e-mail follow-up survey revealed that some of these Offices did not know about all purchasing and regulatory initiatives that may reduce minority health disparities in their states. The state purchasing and regulatory agencies themselves turned out to have relevant information to share but, because offices of minority health focus primarily on health promotion programs, they were not often familiar with the relevant work of their sister agencies.

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AFTER THE GRANT

In 2004, the study's lead investigators, Jill Rosenthal and Neva Kaye, intend to use the findings from this research to develop a toolbox for states to address minority health disparities. The National Academy for State Health Policy is exploring and considering potential funding opportunities for this project. In addition, according to Rosenthal and Kaye, their study provides a foundation for a project funded by the Commonwealth Fund to develop a policy agenda for state lawmakers to eliminate minority health disparities. The Schneider Institute for Health Policy at Brandeis University and the Program to Eliminate Health Disparities at the Harvard School of Public Health are jointly conducting this initiative. (For more information, see the Web site of the Harvard School of Public Health program Racial and Ethnic Health Disparities — States as Catalyst for Change.)

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GRANT DETAILS & CONTACT INFORMATION

Project

Researching the Role of State Purchasers and Regulators in Reducing Racial and Ethnic Health Disparities

Grantee

Center for Health Policy Development-National Academy for State Health Policy (Portland,  ME)

  • Amount: $ 93,305
    Dates: March 2001 to April 2002
    ID#:  041395

Contact

Joan Prouty
(207) 874-6524
jprouty@nashp.org

Web Site

http://www.nashp.org

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Advisory Committee Members

Cheryl Boyce
Executive Director
Ohio Commission on Minority Health
Columbus, Ohio

Tuei Doong
Deputy Director
Office of Minority Health
U.S. Department of Health and Human Services
Rockville, Md.

Brent Ewig
Senior Director for Access Policy
Association of State and Territorial Health Officials
Washington, D.C.

Allan Feezor
Assistant Executive Officer
Health Benefits Section
CalPERS
Sacramento, Calif.

Gregory Franklin
Chief
Office of Multicultural Health
California State Department of Health Services
Sacramento, Calif.

William (Bill) Hagens
Senior Health Policy Advisor
Medical Assistance Administration
Washington State Department of Social and Health Services
Olympia, Wash.

C.J. Hindman
Chief Medical Officer
Arizona Health Care Cost Containment System
Phoenix, Ariz.

Mary Kennedy
Assistant Commissioner, Medicaid Director
Health Care Administration
Minnesota Department of Human Services
St. Paul, Minn.

Lee Partridge
Health Policy Director
American Public Human Services Association
Washington, D.C.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Rosenthal J, Kaye N and Flowers L. State Purchasing and Regulation of Health Care Services: A Snapshot of Strategies to Reduce Racial and Ethnic Health Disparities. Portland, Maine: National Academy for State Health Policy, 2002. Approximately 400 copies distributed to state agencies and policy-makers. Report is also available for purchase on the academy Web site, for $30.

Survey Instruments

"States' Purchasing and Regulatory Strategies to Reduce/Eliminate Racial and Ethnic Disparities in Health Care." National Academy for State Health Policy, fielded to the 35 state Offices of Minority/Multicultural Health, July–November 2001.

"Reducing/Eliminating Racial/Ethnic Health Disparities: The Role of State Purchasers and Regulators, Interview Protocol." National Academy for State Health Policy, fielded to Medicaid agencies, SCHIP agencies, Public Employee Purchasing agencies, Insurance Departments, and Offices of Minority/Multicultural Health in California, Delaware, Massachusetts, New Jersey, New York, Texas, Washington and Wisconsin, November 2001–February 2002.

World Wide Web Sites

www.nashp.org offers state policy-makers easy-to-use, one-stop shopping for information on access, quality and cost issues that related to health care policy. The Web site includes a summary and press release of State Purchasing and Regulation of Health Care Services: a Snapshot of Strategies to Reduce Racial and Ethnic Health Disparities. Portland, Maine: National Academy for State Health Policy.

Sponsored Conferences

"Summit on Reducing Health Disparities for Racial and Ethnic Minorities," February 20, 2002, Chicago. Attended by 21 invitees representing state health care regulatory and purchasing organizations. Three panels:

  • "What can purchasing agencies do to reduce racial and ethnic health disparities?" Discussants: Dolores Mitchell, Massachusetts Group Insurance Commission and Karen Kalaijian, Office of Managed Care, New York State Department of Health.
  • "How can state offices of minority/multicultural health (OMHs) help purchasing agencies in their efforts to reduce racial and ethnic health disparities?" Discussants: Cheryl Boyce, Ohio Commission on Minority Health, and Gregory Franklin, California Office of Multicultural Health.
  • "What do states need to help them move their efforts forward?" Discussants: Jason Cooke, Medicaid/SCHIP Operations, Texas Health and Human Services Commission, and Mary Kennedy, Minnesota Department of Human Services.

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Report prepared by: Karin Gillespie
Reviewed by: Kelsey Menehan
Reviewed by: Marian Bass
Program Officer: Anne F. Weiss

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