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

Primary Question

Previous work has demonstrated that health plans can obtain data on race/ethnicity of enrollees and use the information to identify disparities in quality of care. In the current project, we attempted to take one additional step and address the question: Can managed care plans obtain data on race/ethnicity of enrollees from state Medicaid programs, and, working in collaboration with the Medicaid program and other health plans, use that information to identify and reduce or eliminate disparities in quality of care?

Purpose

The current project was a demonstration project with six closely-related objectives:

• to recruit several state Medicaid agencies to address racial/ethnic disparities in quality of care as an important quality of care issue;
• to recruit one or more managed care plans within each participating State, provide those plans with data on race/ethnicity of members in order to allow analysis of quality of care measures by race/ethnicity, and provide technical assistance to plans as they analyze data and organize quality improvement projects aimed at reducing or eliminating disparities;
• to obtain preliminary estimates of across-plan and within-plan variation in quality of care by race/ethnicity;
• to show that participating Medicaid agencies and health plans can organize and coordinate quality improvement initiatives designed to reduce or eliminate racial and ethnic disparities in quality of care;
• to document the results and impact of quality improvement initiatives developed by participating Medicaid managed care plans; and
• to disseminate findings from the project, in terms of initial experience with data analyses to identify disparities, organization of QI projects, and assessment of impact of those projects on disparities in quality.

The project, which was sponsored by the Health Systems Organization and Financing Group, Health Resources and Services Administration (HRSA), began in September of 2002 and ended June 30, 2004.

Conceptual Framework

We view health care disparities as an important subset of the larger domain of quality of care.[18] Quality of care in the clinical or technical arena is defined for the most part by widely-accepted clinical guidelines developed by medical specialty societies and health care accrediting bodies; these guidelines are in turn based on the results of clinical trials and other types of medical research published in peer-reviewed journals. Other definitions and measures of quality in the interpersonal arena come from concepts of patient-centered care[19] or culturally competent care.[20] Disparities in quality refer to differences in levels of quality for members of different racial/ethnic groups that have no clinical justification.

Managed care plans have contractual responsibilities for quality measurement and quality improvement, and therefore can play a strong role in the identification and elimination of racial/ethnic disparities in quality of care. Public and private purchasers can require that attention to disparities be part of a larger quality improvement agenda; this has begun to happen in both Medicare and Medicaid. A key barrier to health plans’ focusing QI attention on disparities has been their lack of data on race/ethnicity of members, but the ability of state Medicaid programs to share data obtained during program enrollment with managed care plans makes the Medicaid managed care environment particularly attractive for work on disparities in quality of care.

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