While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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.
In its report and an article in Health Affairs, the panel made the following conclusions and recommendations:
The Robert Wood Johnson Foundation (RWJF) supported this project through a solicited grant of $389,240 from January 2004 through December 2006.
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.
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.
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:
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.
In an article in Health Affairs, "Medicare as a Catalyst for Reducing Health Disparities," the study panel concludes that:
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.
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)."
Sharpening Medicare's Tools for Reducing Racial and Ethnic Health Disparities
National Academy of Social Insurance (Washington, DC)
Paul N. Van de Water, Ph.D.
Members of the National Academy of Social Insurance Study Panel on Medicare and Disparities
Bruce C. Vladeck, Ph.D., Chair
University of Medicine and Dentistry of New Jersey
Joseph R. Betancourt, M.D., M.P.H.
Multicultural Education, Multicultural Affairs Office
Department of Medicine
Massachusetts General Hospital-Harvard Medical School
Daniel P. Bourque
Group Senior Vice President
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.
Latinos 2050 (from January 2006)
Foster City, Calif.
Centers for Medicare & Medicaid Services (retired)
Marian E. Gornick, M.S.
Rodney G. Hood, M.D.
Careview Medical Group
San Diego, Calif.
Charles N. Kahn III, M.P.H.
Federation of American Hospitals
Renée M. Landers
Associate Professor of Law
Suffolk University Law School
Maya M. Rockeymoore, Ph.D.
Global Policy Solutions
Reed V. Tuckson, M.D., F.A.C.P.
Executive Vice President and Chief of Medical Affairs
David R. Williams, Ph.D., M.P.H.
Professor of Public Health
Harvard School of Public Health
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:
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:
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:
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:
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.
Study Panel's Recommendations
Quality of Clinical Care
Access to Care
Education of Health Professionals
Capability and Practice of Institutions
Administrative Priorities and Structure
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Eichner J and Van de Water PN. "How Medicare Could Improve Chronic Care, Reduce Disparities." Aging Today, 27(2): 78, 2006. Available online.
Eichner J and Vladeck BC. "Medicare as a Catalyst for Reducing Health Disparities." Health Affairs, 24(2): 365375, 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): 793853, 2005. Available online.
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.
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.
Report prepared by: Robert Crum
Reviewed by: Jayme Hannay
Reviewed by: Marian Bass
Program Officer: Anne F. Weiss
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