Addressing Racial and Ethnic Disparities in the Context of
Medicaid Managed Care: A Six-State Demonstration Project

Background

David R. Nerenz, Ph.D.
Center for Health Services Research
Henry Ford Health System, Detroit

Debra Darling, R.N, B.S.N.
Institute for Health Care Studies
Michigan State University

There is an extensive literature on disparities in health among racial and ethnic groups in the U.S.[1] Although important exceptions can be found, there is a general pattern of poorer health (e.g., life expectancy, self-reported health status, incidence of disease) among members of racial or ethnic minority groups. One contributing factor to disparities in health is disparities in quality of health care; a similarly extensive literature documents disparities among racial and ethnic groups in terms of access to care and quality of care that is received.[2] Since Medicaid programs include mechanisms of accountability for quality of care, disparities in quality of care fall naturally within the scope of Medicaid program responsibility.

Some disparities in health and health care reflect the combined effects of poverty and lack of health insurance.[3] There is ample evidence, though, of disparities in quality of care among employed and insured individuals, even among individuals in a single type of insurance or a single health plan.[4] Although many studies of disparities have focused on individuals insured through either the Medicare program or private insurance, there is also evidence of racial/ethnic disparities in quality for low-income individuals covered by Medicaid. Sample findings include:

• Mexican-American participants in the Arizona Health Care Cost Containment System had fewer prenatal care visits and were less likely to have adequate prenatal care in general than their non-Hispanic White counterparts.[5]
• More African-American and Latino children used hospital-based clinics as a regular source of care (rather than private physician offices) than their White counterparts in a nationally representative sample of individuals covered by Medicaid.[6]
• African-American women with breast cancer had a higher risk of mortality than their White counterparts, in a sample of women insured by Medicaid.[7]
• African-American children with asthma, enrolled in Medicaid, were more likely than their White counterparts to been seen in an ER, but less likely to have primary care office visits.[8]
• African-American children enrolled in Medicaid who had been hospitalized for asthma were less likely than their White counterparts to have primary care follow-up visits.[9]

Health Plans, Quality Improvement, and Disparities

Simply identifying and reporting disparities is not sufficient to reduce or eliminate those disparities. Reducing or eliminating disparities in quality of care requires changes in policies and practices at state, community, health plan, provider organization, and individual provider levels.[10]

Managed care plans are an important organizational locus of quality improvement. Health plans occupy a central position in a “health care accountability chain”[11] in which they are accountable to public and private purchasers for quality of care provided to program beneficiaries or company employees and dependents. Managed care plans create and manage networks of providers, measure and report on quality of care, and support Quality Improvement (QI) programs that seek to improve plan performance on specific, quantitative, measures of quality.

Managed care plans measure quality using standard metrics like those in the Health Plan Employer Data and Information Set (HEDIS)[12] and work to improve their scores on those measures over time. They may disseminate practice guidelines to providers and generate provider profiles that describe performance relative to guidelines. They may have member education and direct outreach programs, or support Disease Management (DM) or case management programs for members with chronic illnesses. Many plans conduct focused quality improvement projects as part of their requirements for accreditation through the National Committee for Quality Assurance (NCQA).[13]

Quality of care measures reported at the aggregate (i.e., plan-wide) level do not help identify racial/ethnic or Socio Economic Status (SES)-based disparities in quality of care, although any such disparities are reflected in the overall level of quality in the plan. Quality of care measures reported for specific regions, market areas, clinic sites, or provider networks within large health plans may hint at the existence of racial/ethnic disparities, but the inferences will be indirect unless there are marked differences in the racial/ethnic composition of health plan members in these regions or networks and few competing explanations for any observed differences in quality. These considerations have led to calls for analysis and reporting of quality of care information explicitly stratified by race and ethnicity.[14]

Although plans could conceivably report many or all of the HEDIS measures separately by race and ethnicity, few currently do so.[15] A key barrier to the reduction of disparities in quality of care for members of racial or ethnic minority groups is the absence of data on race or ethnicity in either health plan databases or in the claims and encounter databases maintained by providers in the plans' delivery networks. If plans do not have information on the race/ethnicity of plan members, it is impossible to calculate the performance statistics that would be useful in identifying disparities in quality of care. One primary point of contact for obtaining race, ethnicity, and language data would appear to be the purchaser, including state and federal governments and private employers. Their support in obtaining accurate and consistent information from enrollees (including consistent definitions of ethnicity that the enrollee or employee accepts and acknowledges as accurate), and providing that information on a regular basis to the health plans, could reduce a major barrier to health plans’ being able to address disparities as a quality of care problem.

Some public purchasers are filling this gap. Purchasers can play an important role in eliminating disparities by: (a) providing data on race/ethnicity of health plan enrollees from eligibility or program enrollment files; (b) requiring health plans to analyze quality of care data separately by race/ethnicity and provide regular reports; and (c) using a variety of mechanisms inherent in the purchaser-supplier relationship (e.g., incentive payment systems) to focus attention on the disparity problem and change clinical practice.[16] Recent demonstration projects supported by the Commonwealth Fund and HRSA have shown that this information can be linked to health plan quality of care data to generate reports that identify disparities in quality of care at the individual health plan level.[17]

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