Anne C. Beale, MD, MPH, the president of the Aetna Foundation speaks about disparities in child health care, the causes behind those disparities, and policies that can reduce them.
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Disparities in Children's Health
1. Hedge Funds 2/28/04 POLICIES TO REDUCE DISPARITIES IN CHILD HEALTH CARE Anne C. Beal, MD, MPH President Aetna Foundation, Inc .
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4. Black Infants are Four Times More Likely to Die than White Infants in Westchester Deaths per 1,000 Live Births, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf
5. Black Children Are Three Times More Likely to Die Than White Children in Westchester Deaths per 1,000 Population, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf
6. Average Length of Stay for Pediatric Hospitalization By Race, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf
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9. Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level. BMC Health Services Research. 5:76. What Causes Disparities? -0.783 Heavy Drinking +0.821 Income +0.872 Physicians +0.836 Unemployment -0.814 -0.727 Per Capita Health Expenditure +0.652 Life Stress Life Expectancy Diabetes Asthma
10. What Causes Disparities? Co-Morbid Conditions Access To Care/Coverage Quality of Healthcare Patient Adherence Genetic Predisposition Community Factors Environmental Factors Cultural Factors Economic Factors Physiologic Response to Meds Ease of Lifestyle Changes
11. WHAT CAUSES DISPARITIES? Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Patient Adherence Ease of Lifestyle Changes Physiologic Response to Meds Disparities
12. WHAT CAUSES DISPARITIES? Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Patient Adherence Ease of Lifestyle Changes Physiologic Response to Meds Disparities
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14. Minority Children are More Likely to Lack Insurance Coverage 23 20 23 37 Percent of Children Ages 0-18 Uninsured All or Part Year, 2000 Source: Adapted from Doty, MM. Insurance, Access, and Quality of Care Among Hispanic Populations. 2003 Chartpack. The Commonwealth Fund and Columbia University analysis of MEPS 2000.
15. Racial Disparities in Clinical Quality Occur Among the Insured Source: Eric C. SchneiderM.D., Alan M. Zaslavsky, Arnold M. Epstein, M.D. “Racial Disparities in Quality of Care for Enrollees in Medicare Managed Care.” Journal of the American Medical Association, vol. 287, no. 10 Percent of Medicare managed care beneficiaries receiving service
28. Percent of adults 18–64 LARGE PROPORTIONS OF MINORITY PATIENTS USE PRIVATE DOCTORS AS THEIR REGULAR SOURCE OF CARE * Compared with whites, differences remain statistically significant after adjusting for insurance or income. Source: Commonwealth Fund 2006 Health Care Quality Survey.
29. CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS Half of All Minority Patients Are Treated by One-Third of Primary Care Physicians Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230 Not an 80:20 rule, but a 80:50 rule
30. Source: David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, and Vincent Mor,Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes, Health Affairs, Vol 26, Issue 5, 1448-1458 85% 20% CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS
31. PRACTICES WITH MORE MINORITY PATIENTS REPORT MORE PROBLEMS WITH QUALITY Percent Quality Problems by Proportion of Minority Patients Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230
32. <15% Black 15-35% Black >35% Black NE MW South West % Black Region NICU Volume >40 Infants <40 Infants Odds Ratio Source: Morales LS et al. Mortality among very low-birthweight infants in hospitals serving minority populations. American Journal of Public Health. Dec 2005. Vol 95, No. 12. Infant Mortality Is Higher in Hospitals with More Minority Patients
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34. Source: Commonwealth Fund 2006 Health Care Quality Survey. Hispanics Are Least Likely to Report Their Providers Have Indicators of a Medical Home Among those with a regular doctor or source of care . . . 62 60 65 68 66 93 Doctors’ office visits are always or often well organized and running on time 26 15 34 28 27 47 All four indicators of medical home 66 60 69 65 65 92 Not difficult to get care or medical advice after hours 84 76 82 88 85 121 Not difficult to contact provider over telephone 84 57 79 85 80 142 Regular doctor or source of care Asian American Hispanic African American White Percent Estimated millions Indicator Percent by Race Total
35. Percent of adults 18--64 reporting always getting care when they need it *Compared to Whites, differences remain statistically significant after adjusting for income Source: 2006 Commonwealth Fund Health Care Quality Survey Hispanics And Asians Are Less Likely to Report Always Getting Medical Care When Needed
36. Racial and Ethnic Differences in Getting Needed Medical Care Are Eliminated When Adults Have Medical Homes Percent of adults 18–64 reporting always getting care they need when they need it Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey
37. *Compared to Whites, differences remain statistically significant after adjusting for income or insurance Source: 2006 Commonwealth Fund Health Care Quality Survey Percent of adults 18—64 able to get an appointment same or next day Hispanics and Asians are Less Likely To Get Rapid Access to Medical Appointments
38. Minorities Who Have Medical Homes Have More Rapid Access to Medical Appointments Percent of adults 18–64 able to get an appointment same or next day * Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey
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40. Cultural Competency Improves Quality of Care Preventive medication underuse among children with persistent asthma Cultural Competency Score Source: Lieu TA et al., Cultural Competence Policies and other Predictors of Asthma Care Quality for Medicaid-Insured Children. Pediatrics 114, no. 1 (2003), e102-e110.
41. Promoting Cultural Competency in Healthcare Raise Awareness Develop Measures of Processes and Outcomes Set Standards for Practice Incorporate into QI
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43. People of Color Are Underrepresented in College, Medical School and as Medical Faculty Percent of Students from Underrepresented Groups Source: Manhattan Institute and AAMC Data Warehouse. Previously reported in Beal AC, Abrams M, Saul J. Healthcare Workforce Diversity: Developing Physician Leaders. The Commonwealth Fund. October 2003.
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47. CONTACT US E-mail the Aetna Foundation: [email_address] Aetna Foundation website: www.AetnaFoundation.org Call for Proposals Was Released March 15, 2010
Notas del editor
Cultural competence (policies included in summary score) Recruits ethnically diverse nurses and providers49 (71.0) Recruits bilingual nurses and providers40 (58.0) Attempts to minimize cultural barriers through printed materials34 (48.6) Offers cross-cultural or diversity training26 (39.4) Offers training to providers to develop communication skills16 (23.5) Evaluates the level of cultural competence among providers9 (14.5) Cultural competence summary score (0–6).85 5–611 (18.6) 3–416 (27.1) 1–222 (37.3) 010 (17.0) Communication-related practices Offers access to interpreters52 (74.3) Provides interpreter service via telephone41 (63.1) Provides low-literacy health educational materials41 (59.4)
Relative weight of each factor has yet to be determined. May vary according to diabetes outcome-prevalence, sequelae, mortality.
Relative weight of each factor has yet to be determined. May vary according to diabetes outcome-prevalence, sequelae, mortality.
“ Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care” Found significant disparities in care among Medicare beneficiaries for HEDIS measures of breast cancer screening, diabetic eye exam, beta blocker use, and mental illness follow-up (new measure). For example, 54 percent of White beneficiaries received appropriate follow-up after hospitalization for mental illness, compared with 33% of African American beneficiaries. Also found that African Americans were more likely to be enrolled in plans with lower overall quality IOM report – Key findings and recommendations from the report include: Racial and ethnic disparities in health care exist even when insurance status, income, age and severity of conditions are comparable Many sources – including health systems, helath care providers, patients and health plan managers contribute to these disparities Steps need to be taken to increase awareness of disparities among providers, the general public and key stakeholders Strengthening the stability of relationships between patients and providers in publicly funded health plans Promoting consistency and equity in health care through the use of evidence based guidelines Collecting and reporting data on health care access and utilization by patients’ race, ethnicity, SES and where possible, primary language
States have increased enrollment by raising awareness and simplifying enrollment process
Even if children of color gain access to care, they may experience poor-quality care Quality improvement would therefore reduce disparities. Funding programs such as Medicaid typically reimburse at below market rates, and most safety net health systems suffer from chronic underfunding and shortages in resources. As a result, they have fewer resources and are less able to provide high quality care than better resourced health systems.
Figure29 from closing the divide
Cultural competence (policies included in summary score) Recruits ethnically diverse nurses and providers49 (71.0) Recruits bilingual nurses and providers40 (58.0) Attempts to minimize cultural barriers through printed materials34 (48.6) Offers cross-cultural or diversity training26 (39.4) Offers training to providers to develop communication skills16 (23.5) Evaluates the level of cultural competence among providers9 (14.5) Cultural competence summary score (0–6).85 5–611 (18.6) 3–416 (27.1) 1–222 (37.3) 010 (17.0) Communication-related practices Offers access to interpreters52 (74.3) Provides interpreter service via telephone41 (63.1) Provides low-literacy health educational materials41 (59.4)
More involved with medical decision making
Many programs receive funding from several HRSA program President’s budget for fiscal year 2005 calls for a 96 reduction from $294 million in 2004 Health Education and Disempowerment Zone
Overall coordination and monitoring of efforts to reduce disparities Will promote research, public health and health promotion efforts