Five Medicaid Managed Care Organizations Reduce Racial and Ethnic Disparities in Health Care
From 2004 to 2007, the Center for Health Care Strategies (CHCS) worked with groups of state Medicaid agencies and Medicaid managed care organizations to identify best practices to reduce disparities in care among racial and ethnic groups.
- Five Medicaid managed care organizations that participated in the project reported progress in reducing disparities in care. For example:
- Monroe Plan for Medical Care (New York) reported reducing neonatal intensive care unit admissions in 2005 from 11 percent to 4.9 percent among babies of African-American teen mothers.
- Molina Healthcare (Michigan) reported increasing its childhood immunization rate for African Americans from 38.3 percent in 2004 to 58.4 percent in 2006.
- Blue Cross of California reported increasing African Americans' use of its personalized education program for asthma from 0 to 15 percent in eight non-chain pharmacies.
- UPMC for You (Pennsylvania) reported a decline in low-birth weight deliveries for African-American women in Braddock County from more than 20 percent in 2004 to 0 percent in 2005, and a decline from more than 20 percent to about 8 percent among all women in the Braddock area.
- L.A. Care Health Plan (California) enhanced its delivery of pharmacy services to racial and ethnic minorities by providing language labeling in the 10 most common languages of its members to 500 pharmacies.
- Two participating state Medicaid agencies implemented quality improvement goals.
The Robert Wood Johnson Foundation (RWJF) supported the project with a $381,789 grant.
Members of racial and ethnic minority groups are less likely than Whites to receive needed health care and often receive care of lower quality, according to Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, a 2002 report by the Institute of Medicine.
Medicaid, the primary federal/state program providing health care to low-income people, is able to address such disparities in care. In 2003, more than half of the 52 million Medicaid beneficiaries under age 65 were racial and ethnic minorities, according to data from the Centers for Medicare and Medicaid Services (scroll down to Table 14 in this document).
Furthermore, more than 60 percent of Medicaid beneficiaries are in managed care organizations or similar arrangements (scroll down to Table 22 in this document). These organizations are well positioned to improve quality of care because they:
- Have access to state Medicaid enrollment data.
- Have their own patient tracking systems.
- Are well positioned to design, direct, support, test and monitor patient interventions at the health plan and the practice level.
The purpose of this project was to launch three related quality improvement initiatives designed to reduce disparities in Medicaid managed care organizations (MCOs), building upon well-tested approaches that bring together MCOs and state purchasers to improve quality.
Under this grant, CHCS sought to reduce disparities in care among racial and ethnic groups by working with state Medicaid agencies and Medicaid managed care organizations. CHCS used a model it developed for RWJF's Medicaid Managed Care Program (MMCP), consisting of three elements:
- A Best Clinical and Administrative Practices working group, for Medicaid managed care organizations.
- A purchasing institute, for state Medicaid agencies.
- A Quality Summit conference, to broadly disseminate what was learned from the working group and the institute.
Best Clinical and Administrative Practices Workgroup
Based on responses from a June 2004 call for proposals, CHCS selected 12 Medicaid managed care organizations to participate in a workgroup on reducing disparities in care. (For membership, see Appendix 1.)
The workgroup participants designed, implemented and evaluated activities to reduce disparities within their respective plans. Over a two-year period the workgroup held three two-day workshops, and CHCS staff provided technical assistance between meetings.
In November 2004, CHCS held a two-day workshop, "Purchasing Institute," for 12 state Medicaid agencies. (For participants, see Appendix 2.) Workshop leaders focused on how to obtain racial and ethnic data and analyze it to identify health disparities. They also suggested disparity reduction and quality improvement measures that states might require of their managed care contractors.
Before the workshop, CHCS conducted a survey of the 12 participating agencies that explored how they collected racial and ethnic data from their beneficiaries. (See the survey results.)
CHCS held a two-day quality summit conference, "Improving Health Care for Racially and Ethnically Diverse Populations" in December 2006. About 135 participants explored strategies to engage states, health plans, consumers and providers in reducing disparities.
CHCS staff developed and tested a new tool, the disparity index, during the project. The disparity index identifies the average disparity in the quality of care experienced by members of racial and ethnic minority groups within the health plan across several clinical measures. The index, if calculated regularly, can indicate changes in disparities. The index was not finalized under the project, however, both because others including the CDC were working on comparable tools and CHCS itself developed broader mechanisms for tracking progress on disparities.
The Commonwealth Fund contributed $211,941 to this project. CHCS also applied $208,199 it received from RWJF as part of the Medicaid Managed Care Program.
Based on the work of the Best Clinical and Administrative Practices Workgroup, CHCS developed the Reducing Racial and Ethnic Disparities: Quality Improvement in Medicaid Managed Care Toolkit. Supplementary resources for the toolkit are also available online. CHCS sent copies to Medicaid directors in every state and to all regional quality improvement organizations serving Medicare. Attendees at the quality summit also received a copy. The toolkit has been well received by Medicaid stakeholders and is frequently downloaded (more than 2,000 times) from CHCS' Web site.
A November 2004 webcast, Leveraging Data to Reduce Racial and Ethnic Health Disparities, shows key purchasing institute sessions. A May 2006 webinar, Addressing Racial and Ethnic Health Disparities: Effective Approaches for Data Collection and Health Plan Partnerships, featured best practices for reducing disparities for health plans and states and was attended by more than 250 participants from across the country. Resources from the 2006 CHCS Quality Summit is also available on the center's Web site.
CHCS staff wrote two issue briefs:
- Using Data on Race and Ethnicity to Improve Health Care Quality for Medicaid Beneficiaries (June 2006) discusses how states can use data on race and ethnicity to improve care.
- From Policy to Action: Addressing Racial and Ethnic Disparities at the Ground-Level (August 2007) outlines strategies states and Medicaid managed care organizations are pursuing to address gaps in care.
Project staff reported the following results to RWJF:
- CHCS published a toolkit of strategies for addressing disparities in care. Reducing Racial and Ethnic Disparities: Quality Improvement in Medicaid Managed Care Toolkit includes key lessons in addressing disparities, covering such activities as:
- Collecting and analyzing data
- Designing patient-centered and culturally-sensitive care
- Encouraging collaboration.
- Five plans that participated in the Best Clinical and Administrative Practices Workgroup reported progress in reducing disparities in care:
- Monroe Plan for Medical Care (New York) reduced neonatal intensive care unit admissions in 2005 from 11 percent to 4.9 percent among babies of African-American teen mothers through the involvement of a culturally appropriate outreach worker.
- Molina Healthcare (Michigan) increased its childhood immunization rate for African Americans from 38.3 percent in 2004 to 58.4 percent in 2006 by working with the health department to visit provider offices and by initiating targeted member interventions.
- Blue Cross of California increased African Americans' use of its personalized education program for asthma from 0 to 15 percent in eight non-chain pharmacies. The education was conducted when members picked up their medications.
- UPMC for You (Pennsylvania) reported a decline in low-birth weight deliveries for African-American women in Braddock County from more than 20 percent in 2004 to 0 percent in 2005, and a decline from more than 20 percent to about 8 percent among all women in the Braddock area. It used a multifaceted approach that included personal outreach and public awareness efforts.
- L.A. Care Health Plan (California) enhanced its delivery of pharmacy services to racial and ethnic minorities by providing language labeling in the 10 most common languages of its members to 500 pharmacies with high caseloads of Medicaid consumers who speak limited English.
- Blue Cross of California (2006)
- Molina Healthcare (2006)
- Monroe Plan for Medical Care (2007)
- UPMC for You (2007)
- Two states reported implemented goals established at the purchasing institute and broader lessons were recognized by all states:
- Florida requires its managed care plans to develop quality improvement projects that focus on health disparities and linguistically appropriate services.
- Michigan held a health literacy workshop for its health plans, to ensure that beneficiaries are able to obtain and understand the basic health information they need to make appropriate health decisions.
- All participating states acknowledged the value of data analysis to identify disparities and several planned on incorporating disparities goals into health plan contracts.
- Reduction in disparities must begin with the collection of good data on race, ethnicity and language preference. These data can be tracked and are worth tracking by states and health plans as a mechanism to help identify, stratify and target outreach and interventions to beneficiaries. "That is something we would be comfortable recommending to any state or health plan Medicaid or commercial going forward," noted Stephen A. Somers, Ph.D. (Project Director).
In addition, the project generated the following specific lessons for states and health plans.
States can help reduce disparities in care by:
- Strengthening and standardizing efforts to collect information on the race and ethnicity of enrollees, either directly or indirectly.
- Incorporating disparities reduction goals and objectives into health plan and provider contracts.
- Linking monetary incentives to initiatives to reduce disparities in health care.
- Analyzing use and performance data by race and ethnicity to identify disparities and target patient and provider interventions.
- Increasing access to culturally and linguistically appropriate care.
- Developing community-based strategies to reach out to minority members.
- Recognize that Medicaid and commercial insurance plans require different approaches. In its broader work, the Center for Health Care Strategies tried to generate synergy between Medicaid plans and the National Health Plan Collaborative, which consists primarily of commercial plans, but discovered that the two types of plans have very different orientations. The Best Clinical and Administrative Practices Workgroup (BCAP), an intervention tool designed for plans working at the ground level with doctors and patients, worked well for Medicaid. It did not work for commercial insurers who are operating at a much higher, national level. (Program Officer/Weiss and Project Director Somers)
AFTER THE GRANT
In March 2007, CHCS used RWJF Medicaid Managed Care Program resources to conduct the Practice Size Exploratory Project. The project goal was to explore the relationship between practice size and quality of care in Medicaid practices in four states. In October 2008, CHCS launched Reducing Disparities at the Practice Site, an additional RWJF-funded program that evolved out of this initial set of disparities-focused projects. This initiative was designed to help states and MCOs support quality improvement in small practices serving a high volume of racially and ethnically diverse Medicaid beneficiaries.
CHCS also managed the National Health Plan Collaborative, a multiplan partnership that sought to reduce racial and ethnic disparities among large, primarily commercial, health plans with a total of 76 million beneficiaries. Phase Two, which began in October 2006, included efforts on collection of primary patient race, ethnicity and language data. The collaborative was funded by the Agency for Healthcare Research and Quality and RWJF.
GRANT DETAILS & CONTACT INFORMATION
Reducing Racial and Ethnic Disparities in Health Care: A Best Clinical and Administrative Practices Initiative
Center for Health Care Strategies Supporting Organization Inc. (Hamilton, NJ)
Dates: May 2004 to January 2007
Medicaid MCOs That Participated in the Best Clinical and Administrative Practices Workgroup
- Anthem Blue Cross (California)
- Healthfirst (New York)
- Helix Family Choice (now known as MedStar Family Choice) (Maryland)
- L.A. Care Health Plan (California)
- Medica (Minnesota)
- Molina Healthcare (Michigan)
- Monroe Plan for Medical Care (New York)
- Neighborhood Health Plan of Rhode Island
- Network Health (Massachusetts)
- Oregon Collaborative (Oregon)
- UPMC for You (Pennsylvania)
State Medicaid Agencies That Attended the Purchasing Institute
- District of Columbia
- New Jersey
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Martin C. Reducing Racial and Ethnic Disparities: Quality Improvement in Medicaid Managed Care Toolkit. Center for Health Care Strategies, 2007. Available online. Additional resources are also available online.
Angeles J and Somers SA. From Policy to Action: Addressing Racial and Ethnic Disparities at the Ground-Level. Center for Health Care Strategies, 2007. Available online.
Llanos K and Palmer L. Using Data on Race and Ethnicity to Improve Health Care Quality for Medicaid Beneficiaries. Center for Health Care Strategies, 2006. Available online.
Audio-Visuals and Computer Software
Leveraging Data To Reduce Racial and Ethnic Health Disparities. Webcast of key sessions of the Purchasing Institute Meeting held in November 2004. Center for Health Care Strategies, 2004. Available online.
Report prepared by: Nina Berlin
Reviewed by: Robert Narus
Reviewed by: Marian Bass
Program Officer: Anne F. Weiss