August 2008

Grant Results

SUMMARY

From 2004 through 2006, the National Academy of Social Insurance convened the Study Panel on Medicare and Disparities to examine how Medicare could use its leverage to reduce racial and ethnic health disparities.

Key Results

Key Conclusions and Recommendations

In its report and an article in Health Affairs, the panel made the following conclusions and recommendations:

  • As a social insurance program, Medicare should take the lead in reducing disparities to ensure that all beneficiaries, regardless of race or ethnicity, receive the best possible care.
  • Despite early successes, when it forced hospitals to desegregate as a condition for reimbursement, Medicare has not realized its potential as a catalyst in reducing health disparities.
  • The Centers for Medicare and Medicaid Services (CMS), the federal agency charged with administering Medicare, needs a comprehensive plan for reducing racial and ethnic disparities within the Medicare system.
  • Medicare should take steps to reduce disparities within five broad areas where it has leverage (quality of care, access, provider education, individual and institutional capacity and administrative priorities). Specifically, Medicare should:
    • Improve the ability of individual providers and the health care system to provide high-quality care to beneficiaries who are members of underserved racial and ethnic minorities.
    • Increase the access of underserved minority beneficiaries to health care by promoting programs that provide supplementary coverage, improving access to providers and expanding educational and outreach activities.
    • Educate health professionals to improve the health system's diversity and cultural competence.
    • Hold individual and institutional providers responsible for reducing racial and ethnic health disparities.
    • Make the reduction of disparities a top priority and administrative focus at the CMS.

    (See Appendix 3 for a list of 17 recommendations within these areas.)

Funding

The Robert Wood Johnson Foundation (RWJF) supported this project through a solicited grant of $389,240 from January 2004 through December 2006.

 See Grant Detail & Contact Information
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THE PROBLEM

In a 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine concluded that racial and ethnic minorities tend to receive lower-quality health care than nonminorities. These disparities exist across a range of conditions and health care services, and typically persist when socioeconomic differences, insurance status and access-related factors are taken into account.

The report also found sizable racial and ethnic disparities in health care usage and outcomes among Medicare beneficiaries. African Americans, for example, have a shorter life expectancy at age 65 than Whites, and African-American beneficiaries are more likely than Whites to have chronic conditions, such as hypertension or diabetes. (Westat, Health & Health Care of the Medicare Population: Data from the 2002 Medicare Current Beneficiary Survey, Rockville, Md.)

Medicare's leverage as the largest U.S. purchaser and regulator of health care—the program provides health coverage to 43 million Americans—offers a unique opportunity to reduce disparities not only for its nine million minority beneficiaries, but also for the rest of the health care system. CMS has launched high-visibility quality improvement initiatives in other areas and, with appropriate tools in hand, is likely to view disparities reduction as an enhancement of these activities.

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RWJF STRATEGY

In 2002, the Institute of Medicine issued its Unequal Treatment report, a review of multiple research studies demonstrating that racial and ethnic disparities are real and extensive. According to the report, even when insurance, income, age and severity of conditions are comparable among Whites and non-Whites, non-Whites are less likely to receive the level of care that experts recommend across a range of treatment areas. In response, RWJF focused grantmaking efforts on developing an understanding of the many complex factors contributing to disparities and determining which are most amenable to change.

In 2004, the foundation's Disparities Team strategy aimed specifically at helping health care systems—purchasers, providers and consumers of health care—address racial and ethnic disparities in treatment as a high priority in their ongoing efforts to improve the quality of care for all. RWJF's initial efforts aimed for short-term, measurable improvements within the context of the health care delivery system.

This project was responsive to the Disparities Team strategic objective to reduce racial/ethnic disparities in the care of targeted diseases by 2008.

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THE PROJECT

In 2004, the National Academy of Social Insurance convened the 13-member Study Panel on Medicare and Disparities to determine how Medicare might reduce disparities both for its beneficiaries and throughout the health care system.

The chair of the panel was Bruce C. Vladeck, Ph.D., who in the mid-1990s was the administrator of the Health Care Financing Administration (now CMS), the federal agency that houses Medicare. Other panel members included academics, consultants, health plan administrators and executives of health care companies and provider associations or alliances. (See Appendix 1 for a roster of panel members.)

Specific objectives of the panel included:

  • Identify factors that influence racial and ethnic health disparities among Medicare beneficiaries.
  • Identify applicable findings from recent efforts to reduce health disparities.
  • Examine Medicare's responsibility for reducing racial and ethnic health disparities.
  • Determine which sources of health disparities Medicare should address.
  • Design recommendations to reduce disparities.

The panel met four times during the three years of the grant. To inform discussions, it reviewed existing literature on disparities and commissioned five research papers.

Other Funding

Additional funding included $127,000 from the California Endowment and $35,000 from the Joint Center for Political and Economic Studies.

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RESULTS

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CONCLUSIONS AND RECOMMENDATIONS

In an article in Health Affairs, "Medicare as a Catalyst for Reducing Health Disparities," the study panel concludes that:

  • Medicare should take the lead in reducing disparities. As a social insurance program, Medicare should ensure that "all beneficiaries who contributed to the Medicare Part A Trust Fund, regardless of race or ethnicity, receive the best possible care."
  • Medicare has not realized its potential as a catalyst in reducing health disparities. Medicare demonstrated its leverage in 1965, the year it began, when it forced hospitals to desegregate as a condition for receiving Medicare reimbursement. Nothing since then has had as much impact on racial inequality, although Medicare has introduced a number of programs that have had some success in addressing disparities.
  • The CMS needs a comprehensive plan for reducing racial and ethnic disparities within the Medicare system. The plan should include recommendations for improving data collection and analyses of disparities, systemic and sustained efforts to improve the quality of care provided to racial and ethnic minority groups, and the elimination of discriminatory practices—both intentional and unintentional.

The study panel's final report, Strengthening Medicare's Role in Reducing Racial and Ethnic Health Disparities, contains 17 recommendations, divided into the five areas where Medicare has useful tools for reducing or eliminating disparities. See Appendix 3 for the full list.

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AFTER THE GRANT

In 2007, the National Academy of Social Insurance became a coalition partner of Out of Many, One: A Multicultural Action Agenda for Eliminating Health Disparities, a project of the Summit Health Institute for Research and Education. The campaign is the first ever advocacy coalition led by people of color and dedicated to achieving health parity for the five major racial and ethnic minority groups in the nation. The academy's work with the coalition is funded through a grant of $25,000 from the California Endowment.

As part of the campaign, the project team from the academy will be holding meetings with the federal Social Security Administration to learn more about race and ethnicity data collected by the agency, and to promote more comprehensive data collection in that area. The Social Security Administration is responsible for certifying that a person is eligible for Medicare and for transmitting demographic information about that person to CMS.

The project director noted, "On August 1, 2007, the House of Representatives passed the Children's Health and Medicare Protection (CHAMP) Act (H.R. 3162), which included provisions on using Medicare to reduce racial and ethnic health disparities, as recommended by the study panel. Although these provisions were not included in the House-Senate conference agreement that was vetoed by the president, they are likely to reappear in other legislation.

"Other recommendations of the study panel are included in a bill introduced by Representative Hilda Solis [D-Calif.] for the Congressional Tri-Caucus, the Health Equity and Accountability Act of 2007 (H.R. 3014)."

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GRANT DETAILS & CONTACT INFORMATION

Project

Sharpening Medicare's Tools for Reducing Racial and Ethnic Health Disparities

Grantee

National Academy of Social Insurance (Washington,  DC)

  • Amount: $ 389,240
    Dates: January 2004 to December 2006
    ID#:  050015

Contact

Paul N. Van de Water, Ph.D.
(202) 452-8097
paulv@nasi.org

Web Site

http://www.nasi.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.)

Members of the National Academy of Social Insurance Study Panel on Medicare and Disparities

Bruce C. Vladeck, Ph.D., Chair
Interim President
University of Medicine and Dentistry of New Jersey
Newark, N.J.

Joseph R. Betancourt, M.D., M.P.H.
Program Director
Multicultural Education, Multicultural Affairs Office
Department of Medicine
Massachusetts General Hospital-Harvard Medical School
Boston, Mass.

Daniel P. Bourque
Group Senior Vice President
VHA, Inc.
Irving, Texas

Kathleen Ann Buto
Vice President for Health Policy, Government Affairs
Johnson & Johnson
New Brunswick, N.J.

Nilda Chong, M.D., M.P.H., Dr.Ph.
President
Latinos 2050 (from January 2006)
Foster City, Calif.

Rose Crum-Johnson
Centers for Medicare & Medicaid Services (retired)
Baltimore, Md.

Marian E. Gornick, M.S.
Consultant
Baltimore, Md.

Rodney G. Hood, M.D.
Managing Partner
Careview Medical Group
San Diego, Calif.

Charles N. Kahn III, M.P.H.
President
Federation of American Hospitals
Washington, D.C.

Renée M. Landers
Associate Professor of Law
Suffolk University Law School
Boston, Mass.

Maya M. Rockeymoore, Ph.D.
President
Global Policy Solutions
Washington, D.C.

Reed V. Tuckson, M.D., F.A.C.P.
Executive Vice President and Chief of Medical Affairs
UnitedHealth Group
Minneapolis, Minn.

David R. Williams, Ph.D., M.P.H.
Professor of Public Health
Harvard School of Public Health
Boston, Mass.


Appendix 2

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

Summaries of Five Research Papers Commissioned by the Study Panel on Medicare and Disparities

In Medicare, Race and Ethnicity Data, Marshall McBean, M.D., M.Sc., discusses Medicare's databases and makes recommendations for how they can be improved as a tool for documenting, monitoring and reducing disparities. These recommendations, summarized in a brief, Improving Medicare's Data on Race and Ethnicity, include:

  • The Social Security Administration should collect information on race and ethnicity on Form SS-5 and through the Enumeration at Birth process using the 1997 OMB standards.
  • The Social Security Administration and CMS should develop a program to collect data on race, ethnicity and socioeconomic position at the time of enrollment in Medicare and for enrollees.
  • CMS should re-examine the feasibility, costs and effectiveness of conducting another mailing to persons with race/ethnicity coded as other or unknown, as well as to beneficiaries selected on the basis of surname or place of residence.
  • CMS should evaluate the findings of recent studies of the effectiveness of using lists of surnames to identify the race and ethnicity of enrollees.
  • The federal Department of Health and Human Services should issue guidelines for the uniform and appropriate collection of data on race and ethnicity by health care organizations.
  • Medicare Advantage plans should be required to collect and report to CMS the race and ethnicity of all enrolled Medicare members.

In Individual Physicians or Organized Process: How Can Disparities in Clinical Care Be Reduced? Lawrence P. Casalino, M.D., Ph.D., argues that Medicare can reduce racial and ethnic disparities by offering incentives, such as pay for performance, to individual physicians and medical groups who increase the quality of care. The author cautions that CMS must be careful to avoid the risk of increasing health disparities in devising quality incentives.

He summarizes his recommendations in a brief, Medicare, the National Quality Infrastructure, and Health Disparities:

  • Quality scores should be risk-adjusted. Medicare should carefully consider whether race and socioeconomic status should be added to risk adjustment formulas. It is likely to be easier for physicians to achieve, for example, high rates of mammography screening in an affluent suburb than in a low-income urban area.
  • Medicare should reward both absolute quality scores and improvement over time. This system would give quality incentives to wealthy physician groups that had relatively high scores even prior to the establishment of incentives while also helping relatively poor physician groups (by recognizing their improvement over time).
  • Medicare should carefully study whether quality incentives lead to increased disparities. Medicare might consider this outcome acceptable, at least in the short run, if such incentives seem to be improving care of minorities. If it is unacceptable, Medicare should consider giving incentives directly for reducing disparities.
  • Medicare should develop quality measures aimed at assessing care coordination for patients with multiple complex illnesses.

In Racial and Ethnic Disparities in Medicare: What the Department of Health and Human Services and the Centers for Medicare and Medicaid Services Can, and Should, Do, Timothy Jost identified a number of tools and programs that are available for CMS to use to address disparities. These include:

  • Culturally appropriate education and outreach through national, state and local initiatives. For example, the HORIZONS (Health Outreach Initiative Zeroing In On Needs) Project, launched in 1999, in which CMS has sought to improve health education communication to Medicare beneficiaries from diverse populations who experience barriers to access due to language, location and low literacy.
  • The use of preventive services through Medicare Quality Improvement Organizations, which are nonprofit community-based organizations working to collaborate with beneficiaries and health care providers to improve the quality and effectiveness of health care at the community level.

    In separate projects in 32 states, these organizations are collaborating with provider, government and community groups to design interventions to reduce disparities, focusing on diabetes screening and mammography use for African-American and Hispanic populations.
  • Efforts to address health risks and behavior and chronic disease management through community-based organizations and academic institutions, such as Historically Black Colleges and Universities.
  • Addressing disparities in diagnosis and treatment of cancer and other chronic diseases through Medicare demonstration programs. For example, the 2000 Medicare, Medicaid and SCHIP Benefits Improvement and Protections Act requires CMS to conduct at least nine projects for targeted ethnic and racial minorities for the purpose of developing models and evaluating methods that improve the quality of services in early detection and treatment of cancer.
  • Enhancing the cultural competence of Medicare managed care organizations through its quality regulations for managed care plans. For example, Medicare regulations require managed care plans to ensure that all services, both clinical and nonclinical, are accessible to all members, including those with limited English proficiency, limited reading skills, hearing incapacity or those with diverse cultural and ethnic backgrounds.

In CMS' Programs and Initiatives to Reduce Racial and Ethnic Disparities in Medicare, Ellen O'Brien, Ph.D., inventories CMS programs and initiatives to reduce disparities, including efforts to provide culturally appropriate education and outreach and enhance providers' cultural competency. The author concludes that:

  • Medicare's efforts have had limited reach and impact on racial disparities, despite successes in some areas, such as Quality Improvement Organizations (QIOs).
  • Future initiatives should consider what can be accomplished through broad-based mechanisms designed to improve access and quality for all beneficiaries and what can and should be done through local initiatives.
  • Medicare can assure that resources are distributed in a relatively equitable fashion across the nation and improve quality of care for all beneficiaries. It can also assure that federal outreach and education is linguistically and culturally appropriate and that states and communities have the tools they need to meet local needs.
  • The QIO community-based efforts provide opportunities for local communities to identify disparities and design interventions that may work for their local circumstances.

In "A New Strategy to Combat Racial Inequality in American Health Care Delivery," Dayna Bowen Matthew discusses how the legal system can be used to reduce health care disparities.

  • Title VI of the Civil Rights Act of 1964 was successful in enabling civil rights lawyers to argue for desegregating hospital emergency departments, patient wards and medical staffs in the 1960s.
  • Subsequently, Title VI has proved to be less effective in addressing persistent health care inequalities.
  • A new strategy for using Title VI, proposed in this research paper, would enable individuals to bring claims against providers for defrauding the U.S. government in violation of the Civil False Claims Act (FCA). The False Claims Act is an anti-fraud statute used to create private causes of action where, as in health care, the government has failed to enforce the laws as written.


Appendix 3

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

Study Panel's Recommendations

Quality of Clinical Care

  • Improve the ability of individual providers and the health care system to provide high-quality care to beneficiaries who are members of underserved racial and ethnic minorities.
    • Increase the focus of quality improvement programs on reducing disparities. For example, efforts could focus on increasing use of preventive services and addressing chronic conditions that are most prevalent among specific minority groups.
    • Strengthen the capability of providers, medical groups, health care organizations and the health system to improve quality and reduce disparities. In particular, organized care management processes can do much to improve the capability of providers. These efforts may include:
      • Providing reminders to physicians at the point of care.
      • Enhancing communication between providers and patients.
      • Implementing information technology.
      • Promoting evidence-based guidelines.
    • Structure incentives for quality in ways that will reduce—not exacerbate—disparities. Incentives for improving the quality of care may have unintended effects that adversely affect minority beneficiaries.

      For example, incentives may influence providers to avoid minority patients if they believe such patients will lower their quality scores. In the aggregate, this may reduce the resources available to providers who serve large numbers of disadvantaged minorities.

      Efforts to assess providers' quality of care therefore should account for differences in the populations they serve, including differences in race, ethnicity and socioeconomic status.
    • Ensure that beneficiaries have a primary provider of care. The American health care system suffers from an aggregate shortage of primary care providers, and minority beneficiaries are even less likely to have a primary provider of care. Therefore, all Medicare Advantage plans should assure that their members have a primary provider of care.

Access to Care

  • Increase the access of underserved minority beneficiaries to health care by promoting programs that provide supplementary coverage, improving access to providers and expanding educational and outreach activities.
    • Ensure that minority beneficiaries are enrolled in existing programs that supplement Medicare coverage, including the Medicare drug subsidy and Medicare Savings Programs.

      These programs—including the Qualified Medicare Beneficiary program, Specified Low-Income Medicare Beneficiary program and Qualified Individual program—help Medicare beneficiaries of modest means pay all or some of Medicare's cost-sharing amounts. CMS should work to make these programs stronger by:
      • Improving the targeting of mailings to potential beneficiaries.
      • Providing targeted information to the states.
      • Offering personal assistance to probable eligibles.
      • Adopting specific enrollment goals.
    • Set deductibles and co-payments to encourage the use of services that have the potential of reducing disparities in care.
    • Improve access to providers for minority beneficiaries. For example, Medicare should provide financial incentives for providers to locate in areas with a high percentage of minority beneficiaries, as it does for other underserved areas.
    • Educate beneficiaries and their families about promoting good health and accessing health care services. For example, the 2003 Medicare Modernization Act establishes a three-year demonstration program for stationing Medicare specialists at local Social Security offices. CMS should also experiment with a variety of approaches and settings, such as setting up health information booths at senior centers and houses of worship.

Education of Health Professionals

  • Educate health professionals to improve the health system's diversity and cultural competence.
    • Increase the number of minority providers, medical staff and medical school faculty. For example, CMS should work with the Department of Education and other organizations to draw attention to the need for minority health care professionals. In addition, CMS should exert its leverage to increase the number of minority professionals serving as residents and nonhospital staffs.
    • Encourage and enhance training in cultural competence for providers. Such training should educate providers about the interconnections between race and ethnicity, inequalities in education and income, and disparities in health care and outcomes. It should also teach communications skills, including proficiency in another language and in the use of interpretive services.
    • Ensure that all types of training promote reductions in disparities. For example, training in the use of electronic medical records, evidence-based guidelines and clinical information retrieval should include an emphasis on monitoring and reducing disparities.

Capability and Practice of Institutions

  • Hold individual and institutional providers responsible for reducing racial and ethnic health disparities.
    • Collect the data necessary for assessing, monitoring and targeting disparities. For example, hospitals, Medicare Advantage plans and other providers should be required to collect data on the race and ethnicity of their patient populations, regularly analyze these data and use them to reduce disparities.

      These data should be made publicly available at the provider and health plan level and aggregated at the smallest level that is statistically reliable and does not raise confidentiality issues.
    • Strengthen the role of accreditation organizations in reducing disparities. The Joint Commission and the National Committee for Quality Assurance should require that the hospitals and health plans they accredit take steps to identify and reduce disparities.
    • Ensure that all providers comply with the guidelines for services to patients with limited English proficiency and the standards for providing culturally and linguistically appropriate services issued by the Department of Health and Human Services. For example, the Department's Office for Civil Rights should take a more active approach towards enforcing limited English proficiency guidelines.

Administrative Priorities and Structure

  • Make the reduction of disparities a top priority and administrative focus at CMS.
    • Establish CMS performance goals for the reduction of racial and ethnic disparities among Medicare beneficiaries. CMS should choose a range of clinical and other quality indicators, possibly tied to measures in the National Healthcare Disparities Report, an annual report of the Agency for Healthcare Research and Quality that monitors the nation's annual progress toward eliminating disparities in health care.
    • Enhance the organizational structure of CMS to support the reduction of disparities. CMS should create an office of minority health to serve as the focal point for initiatives to reduce disparities.
    • Address racial and ethnic disparities as a civil rights compliance issue. For example, the Office for Civil Rights should actively pursue its responsibility to identify and prosecute cases of discrimination in the delivery of health care services financed by federal programs.

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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.)

Articles

Eichner J and Van de Water PN. "How Medicare Could Improve Chronic Care, Reduce Disparities." Aging Today, 27(2): 7–8, 2006. Available online.

Eichner J and Vladeck BC. "Medicare as a Catalyst for Reducing Health Disparities." Health Affairs, 24(2): 365–375, 2005. Available online.

Matthew DB. "A New Strategy to Combat Racial Inequality in American Health Care Delivery." DePaul Journal of Health Care Law, 9(1): 793–853, 2005. Available online.

Reports

Casalino LP. Individual Physicians or Organized Processes: How Can Disparities in Clinical Care Be Reduced? March 2005. Available online.

Casalino LP. Medicare, the National Quality Infrastructure, and Health Disparities. Washington: National Academy of Social Insurance, October 2006. (Medicare Brief No. 14.) Available online.

Jost TS. Racial and Ethnic Disparities in Medicare: What the Department of Health and Human Services and the Centers For Medicare and Medicaid Services Can, and Should, Do. 2005. Available online.

McBean AM. Improving Medicare's Data on Race and Ethnicity. Washington: National Academy of Social Insurance, October 2006. (Medicare Brief No. 15.) Available online.

McBean AM. Medicare Race and Ethnicity Data. December 2004. Available online.

O'Brien E. CMS' Programs and Initiatives to Reduce Racial and Ethnic Disparities in Medicare. April 2005. Available online.

The Study Panel on Medicare and Disparities. Strengthening Medicare's Role in Reducing Racial and Ethnic Health Disparities. Washington: National Academy of Social Insurance, October 2006. (Medicare Brief No. 16.) Available online.

Presentations and Testimony

Bach P, Clancy C, Landers R and Howard E, "Bridging the Divide: Medicare's Role in Reducing Racial and Ethnic Disparities," Alliance for Health Reform, January 29, 2007, Available online.

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Report prepared by: Robert Crum
Reviewed by: Jayme Hannay
Reviewed by: Marian Bass
Program Officer: Anne F. Weiss