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May 21, 2002
Chairman Souder, Congressman Cummings, distinguished Subcommittee members, thank you for inviting me to discuss racial and ethnic disparities in health care, and specifically, the findings of the Institute of Medicine's recent report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. According to the IOM's report, racial and ethnic populations tend to receive lower-quality health care than whites, even when age, income, insurance status, and severity of health conditions are comparable. Sadly, this is not a new phenomenon. Both general literature and CMS research data reveal that a consistent gap in health care exists for racial and ethnic populations. In addition, research finds that racial and ethnic populations generally feel that they are treated with disrespect when obtaining health care. The Secretary, Administrator Scully, and I find racial and ethnic health disparities to be unacceptable, as do many of our fellow Americans, and we are committed to working to develop strategies within Medicare, Medicaid, and SCHIP programs to reduce such disparities in health care. Today, I would like to take a few minutes to discuss our Agency's efforts to provide better, and more equitable health care for racial and ethnic populations.
HEALTHY PEOPLE 2010 AND CMS' EFFORTS
Secretary Tommy Thompson has designated two main goals for his Healthy People 2010 Initiative, which sets forth his national health objectives and is designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. These goals are:
Administrator Scully and I are committed to the Secretary's goals of through better prevention, detection, treatment, and by expanding our education efforts. Over the last year, we have taken several steps to address racial and ethnic health disparities, and have implemented a number of projects to reach out to the racial and ethnic communities.
CMS' APPROACH AND ACTIVITIES RELATED TO THE HEALTH OF RACIAL AND ETHNIC POPULATIONS
CMS' racial and ethnic health activities focus on addressing challenges in accessing needed health services and information and in providing opportunities to respond more effectively to the needs of families from racially, ethnically, and culturally and linguistically diverse groups. As CMS administers the Medicare, Medicaid, and State Children's Health Insurance programs, the Agency is committed to serving all our beneficiaries regardless of race and ethnicity. The cornerstone of our approach is twofold: to increase the visibility and importance of this issue within the Agency and to develop forums for discussion and change.
We work on two levels to reduce disparities. First, we employ a broad agency strategy that promotes the use of evidence-based medicine. Evidence-based activities, such as the use of clinical practice guidelines and the reporting of performance measures drive toward care that is similar across population subgroups. Disparities are reduced by the application of these evidence-based practices, while care of the overall population is improved. Second, we work to reduce the disparities caused by differing access to health care services. Examples of both of these strategies are provided throughout this testimony.
We have worked tirelessly to ensure that activities related to race and ethnicity within the day-to-day operations and mission of each of our centers and offices are institutionalized. This includes ensuring equality of access to Federal programs in racial and ethnic institutions of higher learning, along with enhancing workforce diversity, data, research, access to Department services, procurement, and cross-cutting collaboration within HHS. Additionally, in an effort to manage, oversee, and coordinate racial and ethnic health disparity initiatives, we have established a Program Executive position within the Agency who is responsible for addressing these issues. This position reports directly to me. In addition to increasing the issue's visibility through institutional change, we also have developed a number of race- and ethnicity-related discussion forums at CMS. For example, we established a Diversity Open Door Forum and directed a Quality Council to focus on quality and clinical issues that impact people of color. In addition, we have taken actions to address racial and ethnic health disparities that fall into four major categories: outreach and education; quality improvement projects; research and demonstrations.
OUTREACH AND EDUCATION
According to some of the IOM committee's recommendations, reducing disparities in health care for racial and ethnic populations requires increased patient education, more health care providers from racial and ethnic populations, and increased focus and utilization of community-based health care providers and non-medical personnel. CMS is engaged in many outreach and education activities that support the IOM's recommendations for meeting the needs of our racial and ethnic beneficiaries. Other outreach and education activities include:
Our 10 regional offices across the country are involved in a number of outreach activities targeted to underserved Medicare populations. These groups typically face barriers to information because of language, location, culture, literacy as well as disability. For example, our Atlanta regional office tours low-income, rural counties with substantial racial and ethnic populations. We also conduct 7- to 10-day media tours that are targeted toward the 70 counties in the southeastern United States in which the African-American population is greater than 50% to promote our programs. The Dallas regional office operates a special populations project, in cooperation with the National Medical Association and the Office of Minority Health to educate providers on immunization disparities among the African American community.
We are also working through our Horizons Project to improve health education communications to African-American, Hispanic-American, Asian-American/Pacific Islander, and American-Indian and Alaska Native Medicare beneficiaries. We want to reach out to individuals in these populations who we know experience the greatest linguistics and cultural barriers to accessing health-related information. We are taking what we learn and are adapting our program publications as well as video and audio materials so that they are culturally and linguistically appropriate. One significant purpose of this initiative is to develop and share communications guidelines and materials broadly to assist public and private programs communicate effectively with underserved populations. We plan to test the new materials and develop a guide for employees so all out communications and materials are appropriate and effective.
We also have a website for Medicare information, www.medicare.gov. This award-winning website contains a wealth of program, health, and quality information for beneficiaries and their families. Now, Medicare Compare, Nursing Home Compare, Medigap Compare, and ESRD Compare are available in Spanish. In addition, we have translated our Medicare printed publications, such as the annual Medicare and You booklet, into Spanish. We have also made a variety of program information available in Chinese.
Asian American and Pacific Islanders (AAPI) Initiative
We have developed a Hepatitis B Outreach campaign targeting the Chinese and Vietnamese populations in Boston's Chinatown. In addition, we have created a webpage at www.medicare.gov, which offers information to Chinese and have conducted a mammography awareness radio broadcast campaign in 6 major cities across the U.S. In addition, we currently have a workplan to increase this population's participation in preventive health activities, such as mammography outreach, cancer screening and prevention, Hepatitis B immunization, cervical cancer screening, and preventing the transmission of HIV from mother to child. The plan also includes increasing cultural competency in health care providers, and strengthening partnerships with AAPI community organizations.
Historically Black Colleges and Universities (HBCU)
Under this initiative, we developed a health care outreach initiative between HBCUs and Medicaid agencies. Students and personnel from three HBCUs were trained by State Medicaid Agency staff on the eligibility application intake process for the SCHIP and dual-eligibles programs. The HBCUs distributed CMS publications about the Medicare program among African-American populations in rural areas of Mississippi and South Carolina, with special emphasis each month on a particular Medicare covered benefit (breast cancer, colorectal cancer, etc.). In addition, our Atlanta Regional Office (RO) also developed an initiative called "3E" to strengthen operational ties between HBCUs and CMS. The goals of the program are to promote a working relationship with HBCUs, to enhance and educate our managers on HBCUs, and to increase the participation of the Atlanta University Consortium (AUC) in the 3E program. We also designed a HBCU Health Services Research Grants Program to sponsor limited research projects examining health services issues of significance to African-Americans. Finally, we have developed workshops for data users and grant writers to provide researchers and faculty from HBCUs technical assistance on using CMS data and writing competitive grant applications.
Hispanic Agenda for Action
We also have developed an action plan to meet the goals of the President's Executive Order on Educational Excellence for Hispanic Americans. This includes aggressive strategies for improving Hispanic participation in Federal programs in 2002 and beyond. We want to increase Hispanic representation in our workforce; strengthen and support our Hispanic health services research grants program; and strengthen our bilingual capacity. We already have awarded grants to researchers to conduct research on access, utilization, quality of services, and activities related to health screening, prevention, and education of Hispanic American Medicare and Medicaid beneficiaries.
Similar to our work with HBCU, we have developed workshops for data users and grant writers providing technical assistance on using our data and writing competitive grant applications.
We are also working closely with the academic medical community to promote culturally appropriate training in medical schools and continuing education programs to improve providers' knowledge of these issues. Historically non-white colleges and universities are key to our effort. Our goal is to increase providers' interest in serving racial and ethnic groups.
QUALITY IMPROVEMENT PROJECTS
As I mentioned in my introduction, the IOM report found that racial and ethnic groups tend to receive lower-quality health care than whites. Moreover, research has shown that the disparities in the quality of health care delivered to racial and ethnic patients are often associated with poor health outcomes. For example, a number of studies have found that patients from racial and ethnic groups are less likely to be given appropriate cardiac medications or to undergo bypass surgery. Patients from racial and ethnic groups also are less likely to receive the most sophisticated treatments for HIV infection, which could forestall the onset of AIDS. Additionally, racial and ethnic groups are more likely to receive certain less-desirable procedures, such as lower limb amputations for diabetes and other conditions. This disparity in treatment is clearly unacceptable. We are actively involved in efforts to improve health care quality for all our beneficiaries, and have implemented a variety of quality-related initiatives targeted specifically to racial and ethnic groups and other underserved populations.
One example of our success is the End-Stage Renal Disease (ESRD) Program. Prior to the enactment of Medicare reimbursement for dialysis, African Americans were a small portion of prevalent dialysis patients. Currently, there is little difference between African-American and Caucasian ESRD patients in their ability to obtain dialysis. The ESRD Clinical performance Measures Project was our first nationwide study to improve the care of ESRD patients. Our goal was to provide the appropriate dose of hemodialysis, since numerous studies have demonstrated a relationship between low dialysis and high patient mortality. Studies had shown that there was a 60% greater likelihood of an African-American patient receiving a lower dialysis dose than a Caucasian patient. Our strategy for using clinical practice guidelines has shown improvements in the dose of dialysis for all patients at risk. Importantly, blacks realized the largest gains in the dose of dialysis, thereby resulting in a substantial narrowing of the difference between African Americans and Caucasians in achieving adequate dialysis dosage.
Reducing Health Care Disparities through the Quality Improvement Organizations
In coordination through our Quality Improvement Organization (QIOs, formerly Peer Review Organizations), we are raising the quality of care for beneficiaries who are members of disadvantaged groups to the level of all other beneficiaries living in a particular State. Under this initiative for example, QIOs are playing a leading role in improving the delivery of immunizations and mammography, and improving the quality of diabetes care.
The National Quality Assessment and Performance Improvement Project for Medicare+Choice
Each year, all Medicare + Choice organizations (M+CO) participate in quality improvement projects. This coming year we have asked plans to participate in one of two projects. One project is designed to measure plans' successes in reducing clinical health disparities and the other is targeted toward improving plans' efforts to provide linguistically appropriate care services.
Cancer Prevention and Treatment Demonstration
In addition, we are conducting a cancer prevention and treatment demonstration project for racial and ethnic populations in the Medicare program, as mandated by The Benefits Improvement and Protection Act of 2000 (BIPA). Under this initiative, we are identifying and testing cost-effective models of intervention that have a high probability of positively impacting one or more health outcomes – including health status, functional status, quality of life, health-related behavior, consumer satisfaction, health care costs, and appropriate utilization of covered services – among targeted racial and ethic populations. The first phase of the project involves producing a best practices report on primary and secondary prevention interventions among the targeted racial and ethnic populations. The second phase requires that our contracted partner, Brandeis University, design and implement behavioral risk factor reduction and health promotion demonstrations for each of the targeted populations. At the conclusion of the demonstrations, we will deliver a report to Congress on the cost-effectiveness of the projects, as well as the quality of preventive services provided and beneficiary satisfaction. This research will help inform future project and improve overall quality of care for Medicare beneficiaries.
RESEARCH AND DEMONSTRATIONS
The IOM report called for more research in identifying sources of health disparities, as well as determining future intervention strategies. At CMS, we have already developed a research agenda focused on the elimination of racial and ethnic health disparities in delivery of health care. For example, we are supporting several expert research efforts to address health disparities among Medicaid, SCHIP, and Medicare beneficiaries. The goal is to develop recommendations and strategies for shaping our future research agenda as well as developing an overall strategic plan to eliminate health disparities in racial and ethnic populations in all our programs. The expert consultants will focus their initial research on American Indians, Asians and Pacific Islanders, Hispanics, and African Americans. They will perform a thorough review of existing literature and data regarding health and health disparities. Consistent with the Healthy People 2010 Initiative, they will also examine the impact of variables such as income, insurance, access, cost, and culture on health disparities in the following areas: infant mortality; cancer screening; cardiovascular disease; diabetes; HIV/AIDS rates; and child and adult immunization levels.
We also are conducting a two-phase project to examine American Indian/Alaska Native eligibility and enrollment barriers in Medicaid, SCHIP, and Medicare. We plan to analyze data from CMS, IHS, and Census databases to estimate enrollment in the programs as well as identify gaps between eligibility and enrollment in Medicare, Medicaid, and SCHIP. We also plan to perform case studies and set up focus groups to examine barriers to enrollment as well as develop effective strategies for increasing enrollment in these programs.
Additionally, we are currently undertaking a series of disease management demonstration projects within the Medicare+Choice program to explore a variety of ways to improve beneficiary care in the traditional Medicare plan. These projects have particular significance to racial and ethnic populations for two reasons. First, as research conducted by the Blue Cross and Blue Shield Association and released last month reveals, members of racial and ethnic populations with low incomes who do not have supplemental Medigap or employer-sponsored coverage are more likely to enroll in Medicare+Choice. Additionally, the IOM report shows that racial and ethnic groups are less likely to enjoy a consistent relationship with a care provider, and numerous studies report that non-whites are more likely to suffer from chronic conditions, such as diabetes and asthma. For example, research shows that members of racial and ethnic groups have a higher prevalence of diabetes than whites, while asthma has a disproportionate higher rate among non-white children. Several studies have suggested that case management and disease management programs, such as those provided by Medicare+Choice plans, can improve medical treatment plans, reduce avoidable hospital admissions, and promote other desirable outcomes. Coordination of care has the potential to improve the health status and quality of life for beneficiaries with chronic illnesses. We believe disease management is a critical element for preventing the worsening of chronic health conditions, and thus these demonstrations provide beneficiaries, particularly non-white beneficiaries, with greater choices, enhance the quality of their care, and offer better value for the dollars spent on health care.
We recognize that the gross disparities between racial and ethnic groups access to and quality of health care is unacceptable. Over the last year, we have taken several steps to address racial and ethnic health disparities. We have many projects underway and we are committed to reaching out to racial and ethnic communities. These projects will help increase access to information and services, and ultimately, reduce disparities in health outcomes. However, we realize that we have more to do and are committed to working with our partners in the Department and Congress to achieve our shared goals.
Thank you for inviting me to speak on this issue today. As many of you know, eliminating racial and ethnic disparities in health care is both a professional and personal passion of mine, and I welcome any questions you may have for me.
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Last revised: May 23, 2002