CMS’ Programs and Initiatives to Reduce Racial and Ethnic Disparities

1. CMS’ Programs and Initiatives to Reduce Racial and Ethnic Disparities Ellen O’Brien, Ph.D. Research Associate Professor Health Policy Institute, Georgetown University June 28, 2005 AcademyHealth Annual Research Meeting Boston, MA

2. Sources of Racial and Ethnic Disparities in Medicare • Poverty • Language gaps • Cultural barriers • Provider behavior/racial discrimination

3. What is CMS doing? • Research: documenting disparities and their causes (HCBUs, HSIs) • Beneficiary education and outreach: culturally and linguistically appropriate materials and outreach strategies (Horizons, SHIPs, QIOs, HBCUs, CMS regional office initiatives) • Quality improvement: reducing disparities through beneficiary- and provider-focused initiatives (QIOs, QAPI, demonstration projects)

4. Reducing Disparities through Outreach to Diverse Populations • Translation/interpretation • Spanish-language version of Medicare & You • Language line service at 1-800-Medicare • Health Outreach Initiative Zeroing in On Needs (Horizons) • Contractors produced descriptive reports on the populations, health care needs, information needs, media outlets, etc. • African Americans • Hispanics/Latinos • Asian Americans • “Communications Toolkits” designed to improve the agency’s ability to communicate with diverse groups • State Health Insurance Assistance Programs (SHIP) Grants • Grants to selected SHIPs to do outreach to diverse populations • SHIP training • Expanding enrollment of low income Medicare beneficiaries in MSPs includes training module on cultural competency, Spanish language translation

5. Disparities Reduction as a Quality Improvement Activity • Medicare Quality Improvement Organizations (QIOs) • Medicare managed care plans: QAPI projects

6. Disparities Reduction as a Quality Improvement Activity • Medicare Quality Improvement Organizations (QIOs) • New task added in 1999: reduce disparities for underserved populations • dual eligibles • racial/ethnic minorities • rural beneficiaries • Early efforts (1999-2002, 2002-2005) • QIOs identify underserved populations • Design intervention to reduce disparities • Focus on use of preventive/screening services (flu shots, mammography, diabetes testing) • Focus on beneficiary outreach through community partnerships, • To a lesser extent, focus on provider education • Current efforts (2005-2008) • Greater focus on physicians and office staff • Increase providers’ understanding of cultural competency • Increase compliance with the national Cultural and Linguistically Appropriate Services (CLAS) standards (USDHHS/OMH)

7. Medicare QIOs, continued • Impact: Do QIOs reduce disparities? • Perhaps. Interventions to reduce disparity in Black-white mammography screening rate (8 projects) • Baseline disparity (of 10- 11 percentage points) • Disparity reduced in 6 of the 8 states • Screening rate increased all groups, increased more for blacks than whites, disparity reduced by 1 to 4 percentage points • But, QIOs undertake efforts to increase mammography screening for all populations • Difficult to isolate impact of disparities initiatives • Opportunities for replication & expansion?

8. Disparities Reduction as a Quality Improvement Activity • Medicare managed care plans: QAPI projects • Quality Assessment and Performance Improvement (QAPI) • Plans required to undertake a national QAPI project in 2003 to: • reduce clinical health care disparities (CHCD project) (demonstrate improvement in quality of care provided to a racial/ethnic minority group) • Pneumonia • Mammography • Diabetes • Congestive Heart Failure • enhance cultural and linguistic competence (CLAS project) • Improve language services (Identify LEP enrollees, Inform enrollees of right to language services, provider directory, interpreters) • Organizational changes to improve cultural competence (recruit staff, providers who reflect racial/ethnic composition of enrolled population)

9. QAPI, continued • Impact • Are plans able to reduce clinical disparities? enhance cultural and linguistic competence? What works? • No data available on plans’ interventions or the impact of their QAPI projects • Plans report on 2003 projects by October 1, 2005 • 3 QIOs do primary review of PI; CMS approves • Opportunities for replication/expansion? • CMS does not release plan-specific information on what works/does not work. • Future technical assistance could build on what was learned as a result of 2003 QAPI national project • But, national QAPI requirements for MA plans eliminated in 2005 and beyond

10. Demonstration Projects • Cancer Prevention and Treatment Demonstration • Chronic Care Improvement Projects

11. The Cancer Prevention and Treatment Demonstration • Improve early detection and treatment for cancer (reduce disparities) • American Indians (including Alaskan Native, Eskimo and Aleutian) • Asian Americans • Blacks • Hispanics/Latinos • Pacific Islanders • Focus on screening, diagnosis, and treatment • Breast cancer • Cervical cancer • Colorectal cancer • Prostate cancer • Lung cancer (treatment for patients with diagnosis) • Interventions? helping racially and ethnically diverse beneficiaries “navigate” the healthcare system; patient tracking and decision support tools; community health workers, etc.

12. The Cancer Prevention and Treatment Demonstration • Status • Proposals were due March 2005 • 29 received – University health systems, medical association, hospital systems, community-based organizations, large provider group practices • CMS in process of selecting sites • Legislation called for at least 9 sites, but budgets were high, funds may not accommodate 9 sites or a 3-5 year demo • Demo expected to start late fall 2005 • Independent evaluation

13. A Preliminary Assessment of CMS’ Activities • Reducing racial and ethnic disparities needs to be a higher priority activity. • Focus on beneficiaries important, but greater attention needed to changing physician behavior. • Activities have been limited in scope, some are important first steps. • Progress needs to be monitored; difficult to determine what’s working. • Improving care and outcomes for diverse populations matters, focus on disparities reduction should be maintained. • CMS can go well beyond what it is currently doing (Tim Jost).

14. Acknowledgments • Prepared for the National Academy of Social Insurance, Study Panel on Sharpening Medicare’s Tools to Reduce Racial and Ethnic Disparities. • Paper Available at: www.nasi.org/publications2763/publications_show.htm?doc_id=278645 • Thanks to Bruce Vladeck for inviting me to write the paper, and to NASI and the Joint Center for Political and Economic Studies for funding. • Thanks to the many individuals inside and outside of CMS who gave their valuable time to describe these programs and their impact. • Thanks to the Study Panel, and especially to Dan Bourke, Rose Crum-Johnson, Nilda Chong, and June Eichner for their helpful comments. • Please send comments, criticisms, questions to obriene@georgetown.edu