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

Summary of Project Findings

Benefits Identified by Health Plan Participants:

Toward the end of the project, the participating plans were asked to provide feedback regarding their respective QI projects (e.g., benefits, barriers, resource use, cost, etc). Plan representatives reported positive benefits to participating in a project of this nature. Most felt that the project provided them with an opportunity to analyze one or more important subsets of their member populations to focus on specific health care issues and outcomes measurement. The establishment of collaborative relationships between state agencies, participating health plans, and local community agencies/coalitions was seen as a strong positive benefit for plan members. In the two instances where plans within a State focused on the same health care topic and target population, it provided an opportunity to share knowledge, ideas, and combine plan/state efforts. Plans also stated that the topic of racial/ethnic disparities aligned well with ongoing disease/case management activities and worked well with stratification efforts for high-risk conditions. It was important that the project meet multiple objectives and priorities, and be aligned with other identified plan QI initiatives.

Overall, plans indicated that providers were receptive to receiving information about quality of care disparities and addressing issues that would reduce disparities.

Costs for the project including staff-time, interventions, and data measurement, etc., were primarily seen as being related to larger quality improvement efforts for ongoing HEDIS measurement, accreditation, and state Medicaid requirements. A team approach was used by a majority of the plans in developing and implementing the QI project. Teams included staff from various departments including Quality Improvement, Research, Internal Support Services/Programs, Communications, Health and Lifestyle Management, Disease and Case Management, and clerical support.

Several plans indicated that a coordinated approach by the State Medicaid agency across health plans to address disease specific issues such as asthma, diabetes, depression and cardiovascular disease would be beneficial. Plans supporting this concept suggested that Medicaid agencies are in a unique position to facilitate coordinated efforts among their contracted health plans. Two States participating in this project followed this approach requesting that their plans focus on a similar clinical topic (e.g., diabetes).

Benefits Identified by State Medicaid Program Participants:

Similarly, the state Medicaid agencies were asked to comment on their experiences related to the project. States reported that, in addition to working on reducing disparities, they were able to demonstrate the capability of developing and assessing a collaborative QI project. The process allowed for an opportunity to learn about community-based efforts and build relationships. In one of the participating States, the project generated enough interest that the Medicaid health plans held a statewide conference on cultural competency that required the pooling of resources even though it was not a “mandated” requirement.

State Medicaid agencies were pleased at the increased efforts of the plans to increase awareness and educate members and providers on health topics for which disparities in quality of care had been identified. These efforts were felt to enhance member trust and strengthen community relationships.

The project also allowed plans to go beyond what they were already doing in the area of quality by providing an opportunity to better understand minority groups and examine existing HEDIS and other quality data to identify disparities in care. The ability to target an explicit member subgroup and use beneficial interventions specific to that population, including culturally sensitive interventions to improve health outcomes, was seen as being most beneficial.

Although several of the state Medicaid agencies indicated that the project was fairly labor-intensive, they believed that the transfer of data/information to plans was sustainable. States further reported that the process would be less resource-intensive if it was used in conjunction with current QI activities or as a part of a State or federally required QI initiative. With respect to a statewide approach to addressing disparities, an approach that allowed health plans the autonomy to choose from several clinical conditions or quality measures within those conditions was preferred. Not all plans in each State have the same pattern of disparities, so it will not always be possible to develop coordinated projects with all plans in a State focusing on the same target conditions and measures.

Issues/Barriers Identified by Health Plan Participants:

Several barriers were encountered during the initial data analysis phase of the project. Small population sizes for members in some racial/ethnic groups were an issue, particularly for plans using HEDIS hybrid rates for baseline data analysis. (The HEDIS “hybrid method” involves the review of medical records for a relatively small sample of members for whom administrative data [e.g., claims files] did not indicate the presence of a recommended test or procedure [e.g., mammogram, childhood immunization]. In plans with small minority populations on a percentage basis, the number of minority patients in a hybrid method sample could be very small.) The small sample sizes made it difficult to be confident about the stability or significance of apparent disparities in care. Administrative data was used most often due to the increased size of the subgroups; however, these rates did not reflect the additional information captured through medical record review. In several instances, different conclusions about the existence of disparities were drawn when administrative and hybrid measures could both be examined in the same plan.

Several of the plans discovered that their target population was dispersed among affiliated primary care groups rather than in a smaller number of high volume offices as they had expected, which impacted the implementation process.

Plans addressing disparities in Hispanic populations also noted some barriers or problems that did not come up as often or in the same way for plans addressing disparities for African-American populations. These included:

• Definitions of various ethnic groups in Medicaid enrollment files may not match the members’ identification of themselves (i.e., Latino vs. Hispanic vs. Mexican vs. South or Central American). In order for interventions to be meaningful, there needs to be further work to ensure that members are encouraged to accurately report ethnicity and language identifiers and that these identifiers have the same meanings to the members as to those utilizing them for outreach and measurement.
• There is not a direct correlation between Spanish language and Hispanic ethnicity, but language appears to be the key intervention in this population. A comparison of the total Medicaid population in one plan indicated that only 45 percent of the members identifying themselves as Hispanic indicated Spanish as their primary language. Similarly, 12 percent of the people listing Spanish as their primary language identified themselves as other, non-minority, or were designated as unknown ethnicity.
• It is difficult to determine what “cultural” differences should/could be addressed, since these may not be applied universally across all members of an undifferentiated ethnic group like “Hispanic”.
• It appears that providers need to be aware of what may be cultural issues and then be ready to treat members as individuals without assuming he/she automatically carries with him/her the cultural issues ascribed to that group.
• Many minority individuals are reluctant to provide ethnicity information for fear of retaliation or bias.

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